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Issue Identified With CLIA Waived Claims

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This article has been updated. To view the updated information, see Update to “Issue Identified With CLIA Waived Claims”.

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) has identified an issue affecting Clinical Laboratory Improvement Amendment (CLIA) claims. Some claims may have been denied in error due to the lack of a laboratory certification (LC) code on the certificate for related specialty for CLIA waived labs. 

CLIA regulations allow for waived testing under the certificates without identifying the subspecialties. The only LC code tests listed on the CLIA certificate are for non-CLIA waived tests. All CLIA certificates are approved to perform CLIA waived tests. Therefore, if a laboratory has a CLIA certificate, the laboratory is approved to perform all CLIA waived tests.

Providers should stop seeing denials for a lack of LC code beginning June 11, 2024, and should continue submitting claims while the issue is being resolved. Once the issue has been resolved, TMHP will reprocess affected claims that were denied in error. Providers will be notified of updates in a future article.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.