Anthem Ohio Clinical Laboratory Improvements Amendments

February 2020 ~

Beginning May 1, claims that are submitted to Anthem Blue Cross and Blue Shield (Anthem) of Ohio 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 will be required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form (or its electronic equivalent). The CLIA Certificate Identification number must be submitted in one of the following ways:

Claim Format and Elements: CMS-1500 

CLIA Number Location Options: Must be represented in field 23

Referring Provider Name and National Provider Identifier (NPI) Number Location Options: Submit the referring provider name and NPI number in fields 17 and 17b, respectively.

Claim Format and Elements: Electronic transaction 837 Professional; Health Insurance Portability and Accountability Act (HIPAA) Version 5010  

CLIA Number Location Options: Must be represented in the 2300 loop, REF02 element, with qualifier of “X4” in REF01

Referring Provider Name and National Provider Identifier (NPI) Number Location Options: Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.

NOTE: 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.

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 May 1, 2020.

^{* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.}

Source(s): February 2020 Anthem Provider News – Ohio;