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Denials Affecting Providers With Multiple CLIA Certifications

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

The Texas Medicaid & Healthcare Partnership (TMHP) identified an issue that caused inappropriate claim denials with explanation of benefits (EOB) code 00488: OUR RECORDS INDICATE THAT THE PROVIDER DOES NOT HAVE THE CLIA CERTIFICATION TYPE AND SPECIALTY CODE PERMISSIBLE FOR THE LAB PROCEDURE, FOR THE DATES OF SERVICE ON THE CLAIM. This issue occurred when a provider had multiple Clinical Laboratory Improvement Amendments (CLIA) certification types. The issue was resolved on December 29, 2023.

TMHP will reprocess any affected claims that are identified. Providers are not required to appeal the claims unless they are denied for additional reasons after reprocessing is completed.

For more information, call the TMHP Contact Center at 800-925-9126.