CommercialReimbursementHigh impact
Reimbursement Policies
EmblemHealth·Provider News
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Starting January 1, 2025, EmblemHealth will only reimburse laboratory services that providers are certified to perform under Federal CLIA regulations. All lab claims must include a valid CLIA Certificate ID number, and CLIA waived tests must use modifier QW.
Action Required
By January 1, 2025: Billing team must verify practice has valid Federal CLIA Certificate and update billing system to include CLIA Certificate ID number on all laboratory claims submitted on CMS 1500 forms. Add modifier QW to all CLIA waived laboratory tests. Update encounter forms to remind providers of CLIA requirements. Claims without valid CLIA certification or missing modifier QW will not be reimbursed.