Clinical Laboratory Improvement Amendment (CLIA) Requirements related to PEMS

Date: September 26, 2025

Attention: Providers

Effective for dates of service on or after: November 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like to remind* providers of an important Provider Enrollment and Management System (PEMS) CLIA revalidation requirement.

Providers performing laboratory services must have CLIA certification for the procedure code billed. If a provider bills for a procedure without appropriate CLIA certification the reimbursement will be denied. The remaining claim lines may continue to process if all other requirements are met.

Background information: *TMHP began communicating this requirement in 2022 when CLIA 355 field was added to the PEMS Master Provider File (MPF). Provider notifications are posted on TMHP.com.

Provider Types included in requirement: There are no system requirements within PEMS for certain provider types to enter CLIA information.However, the Independent laboratory provider types do require CLIA as a prerequisite for enrollment and will be reviewed by TMHP upon submission.

Independent Laboratory Provider Types: 

• 23 Independent Lab/Privately Owned Lab (No Physician Involvement)
• 24 Independent Lab/Privately Owned Lab (Physician Involvement) 

Where to update CLIA information in PEMS: Providers must update their CLIA certifications during their provider enrollment revalidation period in PEMS by clicking the License/Certification/Accreditation tab. Guidance available at www.tmhp.com/topics/provider-enrollment/pems/licenses. 

Required CLIA Information (per location/program):

• Certification Number (a.k.a. CLIA ID Number)
  • Certification Code = Accreditation
  • Issuer Code (License Issue Code = CLIA)
  • Certification Type Code OR CLIA Lab Code
  • Certification Effective Date
  • Certification Expiration Date

Important to note:

• NPI and CLIA ID must both be active.
• A unique CLIA ID is required for each testing location.
• All facilities performing lab tests must hold a valid CLIA certificate.

Resource:Texas Medicaid Providers Manual (TMPPM), Radiology and Laboratory Services Handbook: 2.1.1 Clinical Laboratory Improvement Amendments (CLIA) and 2.1.2 CLIA Requirements.

Timeframe for System Updates: Updates in PEMS may take up to 1 week to reflect for MCOs such as TCHP.

Billing information for QW Modifier:

• Mandatory for procedures on CMS’s waived list if provider holds a Certificate of Waiver or PPMP.
• Must be appended to procedure codes for all applicable CLIA waived or PPM tests.
• The QW modifier indicates compliance with federal CLIA requirements.

Additional billing information:

• CLIA certification specialty type codes are available at https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/lccodes.pdf.
• REF - Prior Authorization Number

• Providers should only appeal previously denied claims after CLIA information is updated in PEMS.

Next step for Providers: Providers are strongly advised to share this communication with their staff and adhere to the guidance provided within. This includes the overall maintenance of the ongoing PEMS revalidation requirement.

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

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