CLIA Question

lcole7465

Guru
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Toledo, Ohio
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I have a pain management provider that performs UDS in the office and has a CLIA certificate. We bill 80305-QW and we keep getting denials "Provider was not certified/eligible to be paid for this service/procedure on this DOS". I have 2 questions on this:

1. With the CLIA certificate, is any other providers in the office such as a PA or NP eligible under the certificate to perform the test?
2. Does the CLIA certificate cover all the providers in the office?

Thank you
 

thomas7331

True Blue
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It's been a while since I dealt with CLIA numbers, but as I remember it, CLIA numbers are associated with physical location, not with a specific provider. Since CLIA governs laboratory technical services and not professional scope of practice, it should not matter which provider in a particular office has billed the test itself. But the CLIA number on your claim must be valid for the date of service of the claim and for the location where the services were provider as reported in box 32 of the claim form. In addition, the type of CLIA certification must be appropriate to the complexity level of the procedure billed.

If you are receiving this denial for a CLIA waived test, then my guess would be that either 1) the CLIA number was not in effect on the date of service, or 2) the location for which the CLIA number was issued does not match the location that was reported on the claim, or 3) the payer has made an error or does not have the current correct CLIA information, or 4) the denial is not related to a problem with the CLIA number. My suggestion would be to contact the payer and/or your claim software vendor to make sure that your claims are populated correctly and also that the payer's information is up to date with your certification and, if everything else is correct, to find out if in fact the reason for the denial is actually due to a CLIA certification issue.
 
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