Clinical Laboratory Fee Schedule

Mark Your Calendar!

The next data reporting period starts February 1.

IMPORTANT:

On November 12, 2025, Section 6209 of the Continuing Appropriations, Agriculture, Legislative Branch, Military Construction and Veterans Affairs, and Extensions Act, 2026 was passed and delayed data reporting requirements for clinical diagnostic laboratory tests (CDLTs) that aren’t advanced diagnostic laboratory tests (ADLTs). It also delayed the phase-in of payment reductions under the CLFS from private payor rate implementation:

  • The next data reporting period will be from February 1, 2026 – April 30, 2026 and based on the original data collection period of January 1, 2019 through June 30, 2019.
  • A 0% payment reduction will be applied until January 30, 2026, so that a CDLT that isn’t an ADLT may not be reduced compared to the payment amount for that test in CY 2024. From January 31, 2026 - 2028, payment may not be reduced by more than 15% percent per year compared to the payment amount established for a test the preceding year.

What’s the CLFS?

We pay for most clinical diagnostic laboratory tests (CDLTs) based off the weighted median of private payor rates (fee schedule). Typically, we update the payment rates using private payor rates every 3 years. This is based on The Protecting Access to Medicare Act (PAMA).

These amounts are based on information laboratories submit during a data collection period. There are 3 steps in the process:

  1. Collect data (data collection period): Laboratories submit applicable information.
  2. Analyze data (reviewing window): Laboratories and their reporting entities determine whether they meet the majority of Medicare revenues and low expenditure thresholds. Be sure to review and validate applicable information before you report it.
  3. Report data (data reporting period): Reporting entities report applicable information to us. The current data reporting period runs from February  1 – April  30, 2026. Learn more about reporting data.

What’s a private payor?

These are private payors:

  • A health insurance issuer
  • A group health plan
  • A Medicare Advantage Plan
  • A Medicaid Managed Care Organization

What happens next?

After the next data reporting period, there’s a 3-year data reporting cycle for CDLT. We update the rates under the CLFS every 3 years.

When are the rates effective?

We’ve extended the statutory phase-in of payment reductions resulting from implementing the private payor rate.

 

Year

Data Collection Period

Data Reporting Period

Reduction Cap

2020January 1, 2016 – June 30, 2016January 1, 2017 – May 30, 201710%
2021January 1, 2016 – June 30, 2016January 1, 2017 – May 30, 20170.0%
2022January 1, 2016 – June 30, 2016January 1, 2017 – May 30, 20170.0%
2023January 1, 2016 – June 30, 2016January 1, 2017 – May 30, 20170.0%
2024January 1, 2016 – June 30, 2016January 1, 2017 – May 30, 20170.0%
2025January 1, 2016 – June 30, 2016January 1, 2017 –  May 30, 20170.0%
2026January 1, 2016 – June 30, 2016January 1, 2017 – May 30, 201715% (beginning 1/31/2026)
2027January 1, 2019 – June 30, 2019February 1, 2026 – April 30, 202615%
2028January 1, 2019 – June 30, 2019February 1, 2026 – April 30, 202615%

Contact us

For more information

 

Page Last Modified:
11/24/2025 12:15 PM
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