Date: February 23, 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 comply with the Clinical Laboratory Improvement Amendments (CLIA) regulations. To meet these requirements, providers:
- Must submit their CLIA certifications.
- May submit claims only for services that are covered under their current CLIA certification.
Texas Medicaid will reimburse providers for laboratory services only if they:
- Comply with CLIA.
- Have a CLIA certification for the procedure code that they submit on a claim.
Note: Medicaid will not reimburse any claims for a procedure if the provider does not have the appropriate CLIA certification.
Key Requirements
- Providers must have a valid CLIA certification for each laboratory procedure code billed.
- Effective for claims submitted with a Date of Service (DOS) from March 1 through May 31, 2026:
Claims submitted without the appropriate CLIA certification will pay; however, these claims will be flagged indicating that the CLIA information is incorrect. Providers should update this information before June 1, 2026, as the same CLIA error will result in claim denial for DOS on or after that date. - Effective June 1, 2026:
Full CLIA certification validation will be implemented in production. Claims submitted without the appropriate CLIA certification for the billed procedure code will deny. Other claim lines may continue to process if all requirements are met.- TCHP anticipates issuing provider guidance for providers whose CLIA information in PEMS is incomplete or incorrect.
Updating CLIA Information in PEMS
Providers can update their CLIA information in the Provider Enrollment and Management System (PEMS) through PEMS Maintenance – License transactions, PEMS Existing Enrollment transactions, or PEMS Revalidation transactions.
- Disenrolled providers must update CLIA information through a PEMS Reenrollment request.
- Enrolled providers outside their revalidation window may update CLIA information through a PEMS Maintenance or Existing Enrollment request.
- Enrolled providers within their revalidation window must update CLIA information through a PEMS Revalidation request if a revalidation application has already been submitted. Providers may use PEMS Maintenance only if they have not yet started the Revalidation process.
- Note: Once a revalidation application is submitted, a PEMS Maintenance License request cannot be created. CLIA updates submitted through revalidation will reflect in the PEMS MPF once approved.
Guidance is available at www.tmhp.com/topics/provider-enrollment/pems/licenses.
Updates may take up to one week to reflect for MCOs such as TCHP.
Updating CLIA Information During Revalidation
Providers must update their CLIA information during their provider enrollment revalidation by providing the relevant information on the License/Certification/Accreditation tab in PEMS. For more information about updating CLIA information in PEMS, refer to the Licenses/Certifications/Accreditations page on tmhp.com.
Providers can verify their revalidation date and enrollment information in PEMS. A provider can complete their revalidation up to 180 calendar days before their revalidation due date. For more information, visit the How to Apply for Enrollment page on tmhp.com, click Determine Your Application Type, and scroll to the “Revalidation” section.
CLIA Certification Types
To learn about the various CLIA certifications, visit the Types of CLIA Certificates page on the Centers for Medicare & Medicaid Services (CMS) website.
Resources:
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.
