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Provider Inquiry/Maintenance - CLIA Page

You use the Provider Inquiry/Maintenance - CLIA page to view or edit provider associations to labs via CMS-assigned Clinical Laboratory Improvement Amendments (CLIA) numbers. Each CLIA number represents a laboratory services provider that has been certified by CMS to render a particular level of testing and diagnostic services. More than one provider may be associated to a CLIA number, and a provider may be associated to more than one CLIA number.

The Provider Inquiry/Maintenance - CLIA page contains the following pod and panels:

You can open or close certain panels. Click (the plus sign) beside a panel to open the panel. Click (the minus sign) to close the panel.

If you access this page through Provider Inquiry, all fields are view-only.

 

Details/Maintenance Fields

Fields Description
ID The provider's ND Medicaid number.
Name The provider's name.
Type

The type of provider enrolling.

Examples: Group, Individual
Status

The provider's status

Examples: Active, Inactive
P-SYS-ID The provider's internal system identification number. This is a system generated, unique, sequential number.
To go to a specific page, in the Details or Maintenance pod, click the link.

 

CLIA Details Fields

Field Name Description
To add CLIA details, click Add CLIA Details. To view or edit, in the CLIA Details table, click the appropriate row.
CLIA # The clinical laboratory improvement amendment (CLIA) number.
To verify the CLIA number and automatically populate lab’s name, click Validate.
Lab Name or CLIA Name The name of the lab. Automatically displayed.
Begin Date The beginning date of the provider's association with the lab.
End Date The ending date of the provider's association with the lab.
CLIA Medicare Provider Number The provider Medicare number associated with the CLIA number.
CLIA SSN/EIN or TIN The CLIA Social Security number, employer identification number, or tax identification number.
Date Added The date the CLIA was added.
Date Updated The date the CLIA was updated.

Address Line 1

The address for the lab.
City The city for the address.
State The state for the address.
Zip The zip code and extension for this address.
Pay Indicator The pay indicator.

 

Certification Information Fields

Field Name Description
These fields are displayed after the CLIA number has been validated and contain any information that is available.
Lab Type The lab type.
Cert # The certification number.
Begin Date The begin date of the certification.
End Date The ending date of the certification.

 

Specialty Information Fields

Field Name Description
This fields are displayed after the CLIA number has been validated and contain any information that is available..
Lab Specialty The lab specialty.
Begin Date The beginning date of the specialty.
End Date The ending date of the specialty.

 

Version as of 5/16/14.

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