Become a Provider
Thank you for your interest in participating with Magnolia. Non-contracted providers may request a contract by completing the form at the link provided below. Please allow up to 30 days for evaluation and response to your request.
Providers requesting MississippiCAN (MSCAN) or Children's Health Insurance Program (CHIP) must be credentialed through Gainwell and obtain an active MSCAN or CHIP Medicaid ID before requesting a contract.
To complete this process, please visit the MESA Portal for Providers.
Providers requesting Ambetter and/or WellCare will be required to provide the following documents prior to receiving a contract:
- W-9
- Complete Credentialing Application
- Copy of Certificate of liability insurance for facilities and providers (Must not expire within 60 days) Disclosure of Ownership and Control Interest Statement
- Copy of DEA Certificate Collaborating Physician Form
- Copy of Clinical Laboratory Improvement Amendments (CLIA) Accreditation/Site Visit letter
- State License(s) Rate Letter for RHCs
*Additional documents may be requested depending on provider type
Non-contracted Vision Providers, please contact:
Non-contracted Dental Providers, please contact:
Non-Contracted Pharmacy Providers, please contact: