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What CMS is asking for
Under the Protecting Access to Medicare Act, applicable laboratories must report private payer data that CMS uses to set rates on the Clinical Laboratory Fee Schedule. The current reporting window runs from May 1 through July 31, 2026, a schedule set by the Consolidated Appropriations Act enacted in February. Labs must submit, for services furnished from Jan. 1 through June 30, 2025:
- HCPCS codes for each test,
- the associated private payer rates, and
- the volume at each rate.
CMS has mailed letters to hospitals it believes run outreach labs likely required to report. It also highlighted the deadline in its July 9 provider newsletter.
Does your outreach lab qualify?
CMS cannot confirm each lab’s status, so hospitals must make the call themselves. CMS’s quick reference guide for hospital outreach labs walks through the test in order:
- CLIA certification. The lab must hold a CLIA certificate, including a certificate of waiver.
- Billing route. If the lab bills Medicare on the 14x bill type, use those revenues. If it bills under its own NPI, use revenue tied to that NPI.
- Majority of Medicare revenues. Combined lab fee schedule and physician fee schedule revenue must exceed 50% of total Medicare revenue for that billing route.
- Low-volume threshold. Medicare lab fee schedule revenue must exceed $12,500.
The guide notes that labs billing on the 14x bill type will most likely meet the majority test, so many hospitals with meaningful outreach business should expect to report.
Why the data matters to your margins
Lab fee schedule rates are built from the private payer data that labs report. If qualifying hospital labs do not report, future Medicare rates will reflect a narrower slice of the market. Accurate and complete hospital reporting is one of the few direct levers providers have over future lab payment.
A checklist for the next three weeks
- Assign an owner in finance or revenue cycle and confirm registration in the CMS data collection system, including submitter and certifier roles.
- Document the applicability test, with the revenue figures used, for audit purposes.
- Pull first-half 2025 paid claims by code and payer, and reconcile rates to remittances, not chargemaster amounts.
- Leave time for the certifier to review before July 31.
Archive entry for Jul 9, 2026, added Nov. 11, 2026.