Date: August 11, 2025
Attention: All Providers
Call to action: Texas Children Health Plan (TCHP) would like to inform providers of some Clinical Laboratory Improvement Amendment (CLIA) updates.
CLIA Updates for Laboratory Procedure Codes
Effective for dates of service on or after January 1, 2020, procedure code 87563 will be subject to 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:
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.
Effective for dates of service on or after July 1, 2016, CLIA procedure code 87430 will require the QW modifier. The Texas Medicaid & Healthcare Partnership (TMHP) may reprocess claims with procedure code 87430 for dates of service on or after August 1, 2023.
These updates will be included in the August 2025 edition of the Texas Medicaid Provider Procedures Manual (TMPPM) of the following handbooks:
- Radiology and Laboratory Services Handbook, section 2.2.13, “Microbiology”
- Healthy Texas Women Program Handbook, section 2.3 “Services, Benefits, Limitations, and Prior Authorization”
- Children’s Services Handbook, section 4.3.1.6, “Laboratory Test”
- Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Laboratory Services, section 25.2.11, “Microbiology”
TMHP will deny claims 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.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts,log into: www.texaschildrenshealthplan.org/provideralerts.
