You received this denial for one of the following reasons: 1) the date of service (DOS) on the claim is prior to the provider’s Medicare effective date or after his/her termination date, 2) the procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or 3) the laboratory service billed is missing a required modifier.

To prevent this denial in the future:

Submit claims for services rendered on / after the provider’s effective date, and prior to the provider’s termination date.

• Double-check the DOS on your claim.
• Confirm the provider’s enrollment information through the internet-based PECOS.
  • Note: A provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or, for a future date, up to 60 days from receipt of application.
  • If you require additional assistance regarding a provider’s effective or termination date, you may contact Provider Enrollment. Refer to the Provider Enrollment page for additional information.

If you’re billing for a laboratory service, verify that the service / procedure code is listed as approved under the scope of the provider’s CLIA certification, and if a modifier is required, add a valid modifier to the claim.

• Refer to the complete list of downloads of Categorization of Tests on the CMS website.
• Refer to the list of tests granted waived status under CLIA to determine if the procedure code you’re billing requires the modifier QW (CLIA waived test).

Resubmitting your claim: 

If an error was made, make the necessary correction, and resubmit corrected line item(s) only. Resubmitting non-corrected line item(s) will result in a duplicate claim denial. If a reopening request is applicable, you may submit your request, via the SPOT or the Interactive Voice Response (IVR).