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NOTICE: Medicaid and CHIP Providers Billing Laboratory Services Subject to CLIA Certification Requirements

Date: 02/13/26

All providers servicing Superior HealthPlan’s Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS) and CHIP members must enroll to participate in the Medicaid and CHIP Programs through the Texas Health and Human Services Commission (HHSC), in addition to being contracted by Superior to provide Medicaid and CHIP covered services to our members. HHSC provider program enrollment process includes requirements for providers who are delivering laboratory services to include applicable Clinical Laboratory Improvement Amendments (CLIA) certification information into the Provider Enrollment Management System (PEMS).

To ensure compliance with federal CLIA certification requirements, HHSC requires all Medicaid and CHIP providers providing and billing for laboratory services have entered the applicable CLIA certification information into PEMS, in order to validate those certifications through the Center for Medicare and Medicaid Services CLIA database.

In addition, HHSC requires that all Texas Medicaid and CHIP Managed Care Organizations (MCOs) verify that all providers billing laboratory services have the applicable and appropriate CLIA certifications upon receipt of claims, and the CLIA certification information is present and active in PEMS. This requirement includes laboratory providers, hospital providers, physician based groups, individual practices and clinics who are submitting claims for laboratory services.

HHSC is requiring all Texas MCOs to provide notice to providers who do not have the appropriate CLIA certification in the HHSC PEMS provider enrollment system for laboratory services billed on managed care claims for services date on and after March 1, 2026.

Providers should note the following:

  • To comply with this requirement, providers will receive a WARNING message on the Explanation of Payment (EOP) for laboratory service claims for service dates March 1, 2026, and after, if the provider’s CLIA certification information is not present and active in the HHSC PEMS system for the service code and date of service billed on the claim.
    • The EOP will reflect the following WARNING message: EX1Q: EX1Q: WARNING: CLIA CERT IN PEMS INCOMPLETE.  AS OF 6/1/26 DOS CLAIMS WILL DENY.
  • The clean claims will process for reimbursement as applicable for laboratory services from March 1, 2026, through May 31, 2026.
  • Beginning with service dates June 1, 2026, and after, the laboratory service claims will deny if the appropriate CLIA certification information is not present in PEMS.
  • All providers should immediately confirm that all applicable CLIA certification information has been properly entered and present in the HHSC PEMS system and maintain updated CLIA certification information in PEMS as those certifications are renewed or changes made.

For any questions regarding these requirements, please contact your Provider Representative. To access their contact information visit Find My Provider Representative.