Action Required: CLIA Certification Required to Avoid Claim Denials Starting June 1, 2026

Date: March 26, 2026

Attention: All Providers

Effective June 1, 2026: Claims without appropriate CLIA certification will be denied

Texas Children’s Health Plan (TCHP) reminds providers that all laboratory service providers must maintain the appropriate Clinical Laboratory Improvement Amendments (CLIA) certification to be reimbursed for lab services. Claims without valid CLIA certification will deny beginning June 1, 2026.

What Providers Must Do

• Maintain a current and valid CLIA certification that is accurately reflected in the Provider Enrollment and Management System (PEMS).
• Have CLIA certification that is appropriate for the laboratory services provided and subject to reimbursement.

Claims Impact

• Now – May 31, 2026
  • Claims without correct CLIA certification will pay but be flagged.
  • Providers should correct CLIA information before June 1, 2026.
• Effective June 1, 2026
  • Claims without appropriate CLIA certification will deny.
  • Other claim lines may still be processed if all requirements are met.

Important Reminder

• Medicaid will not reimburse laboratory procedures if the provider does not have the correct CLIA certification for the submitted procedure code.

Updating CLIA Information

• Providers must update CLIA information in PEMS.
• Updates may take up to one week to reflect for MCOs, including TCHP.
• Guidance is available at: www.tmhp.com/topics/provider-enrollment/pems/licenses

Resources

• Texas Medicaid Providers Manual (TMPPM), Radiology and Laboratory Services Handbook: 2.1.1 Clinical Laboratory Improvement Amendments (CLIA) and 2.1.2 CLIA Requirements.
• The full list of CLIA certification specialty type codes from CMS can be found in the following link: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/lccodes.pdf
• Previously published Provider Alerts on this topic:
  • https://www.texaschildrenshealthplan.org/news/provider-alert/reminder-clia-certification-required-laboratory-service-claims
  • https://www.texaschildrenshealthplan.org/news/provider-alert/action-required-clinical-laboratory-improvement-amendment-clia-revalidation
  • https://www.texaschildrenshealthplan.org/news/provider-alert/clinical-laboratory-improvement-amendment-clia-requirements-related-pems

Next steps: Providers are strongly advised to share this information with their staff and ensure CLIA certifications are current in PEMS.

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org. 

For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.