REF

Clinical Laboratory Improvement Amendment (CLIA) Number

Pos: 180	Max: 3
Detail - Optional
Loop: 2300	Elements: 2

Ref

Id

Element Name

Req

Type

Min/Max

Usage

REF01

128

Reference Identification Qualifier
Description: Code qualifying the Reference Identification

M

ID

2/3

Required

Code

Name

X4

Clinical Laboratory Improvement Amendment Number

REF02

127

Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Industry: Clinical Laboratory Improvement Amendment Number
NSF Reference: FA0-34.0

C

AN

1/30

Required

1.

R0203 - At least one of REF02,REF03 is required

1.

REF04 contains data relating to the value cited in REF02.

Notes:

1. Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act.
2. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
3. In cases where this claim contains both in-house and outsourced laboratory services: For laboratory services preformed by the billing or rendering provider the CLIA number is reported here; for laboratory services which were outsourced, report that CLIA number at the 2400 loop.

Example:

REF*X4*12D4567890~