Clinical Laboratory Improvement Amendments for Anthem
September 9, 2020Claims 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.
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) beginning October 1, 2020. The CLIA certificate identification number must be submitted in one of the following ways:
| Claim Format and Elements | CLIA Number Location Options | Reffering 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 refferring 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. Clinical Laboratory Improvement Amendments for Anthem Page 2 of 2 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 October 1, 2020.