The Rise of CLIA-Related Rejections: What Labs Should Review

Since CMS transitioned CLIA certification to a paperless system in March, TELCOR has noticed an increase in CLIA-related rejections and denials from commercial payers.  

Though little published documentation is available, our research suggests that some payers are now validating submitted CLIA certificate numbers against CMS CLIA data, leading to increased rejections related to mismatches between submitted information, enrollment data, and CLIA records. Some of the most common causes of these rejections and denials are:

• Mismatch between the address on the provider’s enrollment file and the address on the CLIA record
• Mismatch between the provider’s address submitted on the claim and the address on the CLIA record
• CLIA complexity does not support the billed CPT

Payers like UHC, Humana, Elevance Health (formerly Anthem), and Cigna are likely performing CLIA validation. Even minor discrepancies are now causing errors, so we recommend careful review of enrollment and claim submission data to avoid CLIA-related mismatch errors. 

- Sarah Stewart, Vice President, RCS

UHC: Clinical Laboratory Improvement Amendments (CLIA) ID Requirement Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial and Individual Exchange

CMS: Clinical Laboratory Improvement Amendments (CLIA) | CMS