Texas Medicaid: CLIA certification must be current and active in PEMS

The Texas Medicaid & Healthcare Partnership (TMHP) requires all laboratory service providers enrolled in its Medicaid program to upload their current Clinical Laboratory Improvement Amendment (CLIA) certificate in the state’s Provider Enrollment and Management System (PEMS). The certificate authorizes laboratories to perform tests at a complexity approved by CMS and receive reimbursement for those covered services.

Important timelines

As a TMHP managed care organization, we must verify laboratory certification using data from CMS and PEMS. To support timely and accurate reimbursement, we’ll take the following steps:

• For dates of service between March 1 and May 31, 2026, we’ll include a notice in the laboratory’s provider remittance advice (PRA) if a CLIA certificate is missing, outdated or not reflected in PEMS
• For dates of service on or after June 1, 2026, claims will be denied if the CLIA certificate is missing, outdated or not reflected in PEMS

If your laboratory is certified to perform only waived tests, please include the QW modifier on the claim to prevent processing delays. 

What you can do

Before submitting a claim for laboratory services:

• Verify your CLIA certificate is active and updated in PEMS 
• Ensure the certificate type covers the billed procedure code on the claim
• Enter the QW modifier on claims if your laboratory is certified only to perform procedures included on the CMS waived list 

Resources

• TMHP Licenses/Certifications Accreditations – Includes instructions for reviewing and updating CLIA certification in PEMS 
• CMS.gov Clinical Laboratory Improvement Amendments (CLIA)
• Texas Medicaid Provider Procedures Manual – Radiology and Laboratory Services Handbook