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Claims Reprocessing and QW Modifier Required for CLIA Procedure Code 87430

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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.

Effective for dates of service on or after July 1, 2016, Clinical Laboratory Improvement Amendment (CLIA) procedure code 87430 will require the QW modifier. The Texas Medicaid & Healthcare Partnership (TMHP) may reprocess claims with procedure code 87430 for dates of service on or after August 1, 2023.

TMHP will include this requirement in the August 2025 edition of the Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Services Handbook, section 2.2.13, “Microbiology,” and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Laboratory Services, section 25.2.11, “Microbiology.”

Reminder: Providers must have the required CLIA certification on file, and they must use the QW modifier when it is required, per the Centers for Medicare & Medicaid Services (CMS). TMHP will deny claims if the QW modifier is not present on applicable CLIA-waived tests. Refer to the CMS CLIA website for information about CLIA-waived tests, provider certifications, and billing requirements.

The reprocessed claims may result in additional payment that will be reflected on future Remittance and Status (R&S) Reports.

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