CommercialOctober 31, 2020
Clinical Laboratory Improvement Amendments (CLIA) Number -- Additional Information
Both paper and electronic claim formats accommodate the CLIA number.
- On the CMS-1500 form, Box 23 (Prior Authorization) is reserved for the CLIA number.
- On the 837P, REF segments are available: REF (X4) in loops 2300 and 2400, and REF (F4) in loop 2400.
Note: The CLIA number for the Referring Clinical Laboratory should be included in REF (F4)
The following examples illustrate how the CLIA number as well as procedure code modifiers QW and 90 should be filed:
Claim Format |
Location(s) Reserved for Procedure Modifier and CLIA # |
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Modifier QW – diagnostic lab service is a CLIA waived test · CLIA Waived Tests - simple laboratory examinations and procedures that have an insignificant risk of an erroneous result |
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CMS-1500 |
Procedure modifier ‘QW’: Box 24d |
CLIA #: Box 23 Prior Authorization |
|
837P |
Procedure modifier ‘QW’: Loop 2400 SV101-3 (1st position) |
CLIA #: Loop 2300 or 2400 REF X4 |
|
Modifier 90 – Reference (Outside) Laboratory · Referring laboratory – refers a specimen to another laboratory for testing · Reference laboratory – receives a specimen from another laboratory and performs one or more tests on that specimen |
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CMS-1500 |
Procedure modifier ‘90’: Box 24d |
CLIA #: Box 23 Prior Authorization |
|
837P |
Procedure modifier ‘90’: Loop 2400 SV101-3 – SV101-6 |
CLIA #: Loop 2300 or 2400 REF X4 |
CLIA # - Referring Facility Identification: Loop 2400 REF F4 |
Additional information regarding CLIA is available on the CMS website: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/
If you have additional questions, please call the telephone number on the back of the member’s identification card.
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