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CLIA Updates and Claims Reprocessing for Some Procedure Codes

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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 January 1, 2020, procedure code 87563 will be subject to Clinical Laboratory Improvement Amendment (CLIA) edits.

Effective for dates of service on or after January 16, 2025, TMHP will require the QW modifier for the following CLIA procedure codes:

Procedure Codes
874918756387591       

TMHP may reprocess claims that are submitted with the updated procedure codes and include dates of service on or after January 16, 2025.

The reprocessing of affected claims may result in an additional payment or recoupment, which will be reflected on future Remittance and Status (R&S) Reports.

These changes will be reflected in the Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Services Handbook, section 2.2.13, “Microbiology,” the Healthy Texas Women Program Handbook, section 2.3 “Services, Benefits, Limitations, and Prior Authorization,” the Children’s Services Handbook, section 4.3.1.6, “Laboratory Test,” and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Laboratory Services, section 25.2.11, “Microbiology,” August updates.

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). Claims will be denied 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.

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