Blue Cross Blue Shield of North Carolina Reinforcing CLIA Rules Effective 08/01/2023

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) requires participating providers to provide, as part of their credentialing process, Clinical Laboratory Improvement Amendments (CLIA) certification if laboratory services are rendered in an office, reference laboratory or facility setting. The requirements are outlined currently in The Blue Book provider e-manual and the Professional Pricing Policy. Blue Cross NC is currently monitoring all lines of business to ensure consistency in claims processing per CLIA guidelines.

As a reminder, participating providers are required to bill the CLIA according to their approved certificate.  Payment for in-office laboratory services for providers is limited to those for which the practice has provided Blue Cross NC with evidence of CLIA certification. When applicable, providers must add the –QW modifier (waived test).

If you do not have a CLIA certification, or have not provided Blue Cross NC with that documentation, laboratory codes may not be reimbursed that would have otherwise been reimbursed.  Beginning August 1, 2023, Blue Cross NC will have CLIA edits and rules in place for all lines of business.

If you have questions or need additional information, please contact network management on 800-777-1643 and choose option 6.