3 IN CASE YOU MISSED IT! Update to PEMS for Clinical Laboratory Improvement Amendment (CLIA) In order to stay compliant with the CLIA requirements, a reminder was sent to all providers on April 7, 2023, for laboratory services utilizing CLIAs. Providers must submit their CLIA certifications through the Provider Enrollment and Management System (PEMS) and can bill only for services for which they have an appropriate CLIA certification on file. All providers that bill laboratory services must have CLIA certification for the procedure(s) being billed. If a provider bills for a procedure without appropriate CLIA certification, reimbursement will be denied. Providers must update their CLIA certifications in PEMS under the Licenses / Certifications / Accreditations link and may find more information about updating CLIA certifications in PEMS on the Licenses / Certifications / Accreditations page on tmhp.com. CLIA certification types These are the current CLIA certification types published by the Centers for Medicare & Medicaid Services (CMS): ■Certificate of Waiver. This certificate is issued to a laboratory to perform only waived tests. ■Certificate for Provider-Performed Microscopy Procedures (PPMP). This certificate is issued to a laboratory in which a physician, mid-level practitioner, or dentist performs no tests other than microscopy procedures. This certificate also permits the laboratory to perform waived tests. ■Certificate of Registration. This certificate is issued to a laboratory and enables it to conduct moderate- and highcomplexity laboratory testing until the laboratory is determined by survey to be compliant with CLIA regulations. ■Certificate of Compliance. This certificate is issued to a laboratory after an inspection finds the laboratory to be compliant with all applicable CLIA requirements. ■Certificate of Accreditation. This certificate is issued to a laboratory on the basis of the laboratory’s accreditation by an accreditation organization approved by CMS. stay informed Does your office have a step-by-step claim denial approach? Claim denials are a serious issue that affect your revenue cycle. What is your approach to identifying the root cause of denials? Analyzing data allows you to see where the problems are occurring. Whether the issue is in Patient Registration, Authorizations, Eligibility, or Coding / Billing Errors, claim denials can be very cumbersome. Regular analysis can help you resolve any potential issue before it becomes serious. Always stay on track with all health plan changes to ensure that your staff implements any system changes that affect claims. Top denials El Paso Health (EPH) has identified are: ■Benefit requires Utilization Management (UM). ■Claim is an exact duplicate claim to a previously submitted claim. ■Claim was not submitted in a timely manner (submission window exceeded). ■Authorization on claim not found. ■Authorization dates do not match claim. Remember, EPH has a dedicated team ready to assist you with your claim status inquiries. FOR MORE INFORMATION Call TMHP at 1-800-925-9126.
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