Beginning December 1, 2025, HHSC is requiring a phased approach to claim edits related to CLIA certification Data:
Soft Edit Period (No later than March 1, 2026)
A soft edit will be implemented to help providers correct CLIA information that does not match the PEMS file before hard denials begin.
- The soft edit will not deny CLIA‑related claims when the CLIA information submitted on the claim does not match the CLIA information in PEMS.
- The soft edit will still allow denials to occur when the provider has no CLIA certification on file in PEMS for the laboratory, consistent with current processing.
- The soft edit will generate a warning notifying providers when a billed procedure requires CLIA certification that is not on file in PEMS.
- The explanation of benefits/payment (EOB/EOP) on the provider’s remittance will:
- Inform providers that CLIA certification must be updated in PEMS
- Be provider‑facing, descriptive, and easy to follow
A general provider notification will inform all providers about the soft edit and the upcoming transition to hard edits.
The soft edit must apply for the dates of service (DOS) March 1, 2026. The soft edit will be maintained through May 31, 2026. The soft edit is intended to give providers time to update missing or mismatched CLIA information in PEMS before hard denials begin.
Hard Edit Requirement – Effective June 1, 2026
Beginning with dates of service on and after June 1, 2026, CLIA-related claims will begin to deny if:
- The billed procedure requires CLIA certification and
- The provider does not have the appropriate CLIA certification documented in the PEMS Master Provider File
Claims that do not meet CLIA certification requirements must be denied at this stage.
For assistance updating your CLIA information in PEMS:
- ProviderEnrollment@hhs.texas.gov
- For additional questions regarding this new requirement, please review the FAQ from HHSC.
Providers are encouraged to:
- Review current CLIA certification status and confirm updates are reflected in PEMS.
- Monitor remittance EOB/EOP messages during the soft edit period to ensure compliance before hard edits begin.
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider eNewsletter