The purpose of this article is to provide additional information regarding submission of the CLIA number on claims for laboratory services that include QW or 90 modifiers. As a reminder, claims filed without the CLIA number are considered incomplete and will reject. 

 

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 #

 

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

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

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.

 

If you have additional questions, please call the telephone number on the back of the member’s identification card.

 

733-1120-PN-CNT



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