MedicaidBilling CodesHigh impact
Updated CLIA Certifications and Claims Reprocessing for Certain Procedure Codes
Texas Medicaid·TX · Pathology·General
Effective date
Jun 30, 2026
We identified it
Jul 28, 2026
Summary
TMHP has updated CLIA laboratory certification requirements for 23 procedure codes, effective June 30, 2026. Beginning June 30, 2024, TMHP may reprocess historical claims (back to that date) for these codes, potentially resulting in additional payments or recoupments on future R&S reports. Your practice must ensure all laboratory service providers have current CLIA certifications submitted in PEMS.
Action Required
By June 30, 2026: (1) Billing team must verify all laboratory service providers have submitted current CLIA certifications in PEMS matching the certification levels required for each affected code (certifications vary by code—see policy table). (2) Update billing system to flag or validate that claims for these 23 codes originate from CLIA-certified labs with appropriate certification levels before submission. (3) Accounting/revenue cycle team must monitor future R&S reports starting July 2024 for adjustments related to reprocessed claims (dates of service on/after June 30, 2024) and be prepared to post recoupments or additional payments. (4) If your practice operates or bills laboratory services, submit all CLIA certifications to PEMS immediately via the Provider Enrollment and Management System. Failure to maintain CLIA certifications will result in claim denials for these procedure codes. Contact TMHP at 800-925-9126 (or 800-568-2413 for CSHCN) with questions.