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Reminder: CLIA Certification Required for Laboratory Service Claims

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All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendment (CLIA). To meet these requirements, providers:

  • Must submit their CLIA certifications.
  • May submit claims only for services that are covered under their current CLIA certification.

Texas Medicaid will reimburse providers for laboratory services only if they:

  • Comply with CLIA.
  • Have a CLIA certification for the procedure code that they submit on a claim.

Note: Medicaid will not reimburse any claims for a procedure if the provider does not have the appropriate CLIA certification.

Updating CLIA Information in PEMS

Providers can update their CLIA information in the Provider Enrollment and Management System (PEMS) through PEMS Maintenance – License transactions, PEMS Existing Enrollment transactions, or PEMS Revalidation transactions.

  • If providers are disenrolled, they must update their CLIA information through a PEMS Reenrollment request.
  • If providers are enrolled and outside of their revalidation window, they can update it through a PEMS Maintenance or PEMS Existing Enrollment request.
  • If providers are enrolled and within their revalidation window, they can update their CLIA information through a PEMS Revalidation or PEMS Maintenance request if they have not yet submitted a Revalidation application. Providers that have already submitted a Revalidation application cannot access a PEMS Maintenance request.

Updating CLIA Information During Revalidation

Providers must update their CLIA information during their provider enrollment revalidation by providing the relevant information on the License/Certification/Accreditation tab in PEMS. For more information about updating CLIA information in PEMS, refer to the Licenses/Certifications/Accreditations page on tmhp.com.

Providers can verify their revalidation date and enrollment information in PEMS. A provider can complete their revalidation up to 180 calendar days before their revalidation due date. For more information, visit the How to Apply for Enrollment page on tmhp.com, click Determine Your Application Type, and scroll to the “Revalidation” section.

CLIA Certification Types

To learn about the various CLIA certifications, visit the Types of CLIA Certificates page on the Centers for Medicare & Medicaid Services (CMS) website.

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