Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments (CLIA) 1988 federal statute and regulations require additional information to be considered for payment.

 

Beginning May 1, 2020, a valid CLIA Certificate Identification number is required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form (or its electronic equivalent). The CLIA Certificate Identification number must be submitted in one of the following ways:

 

Claim Format and Elements

CLIA Number Location Options

Referring Provider Name and National Provider Identifier (NPI) Number Location Options

CMS-1500 

Must be represented in field 23

Submit the referring provider name and NPI number in fields 17 and 17b, respectively.

Electronic transaction 837 Professional; Health Insurance Portability and Accountability Act (HIPAA) Version 5010  

Must be represented in the 2300 loop, REF02 element, with qualifier of “X4” in REF01

Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.

 

Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the “QW” modifier when any CLIA Waived laboratory service is reported on a CMS-1500 claim form in order for the procedure to be evaluated to determine eligibility for benefit coverage.

 

Laboratory procedures are only covered and therefore payable if rendered by an appropriately licensed or certified laboratory. Therefore, any claim that does not contain the CLIA ID will be considered incomplete and rejected beginning May 1, 2020.

 

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

 



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February 2020 Anthem Provider News - Kentucky