CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vitamin D Testing Payment Policy

Defines medical necessity criteria, documentation, coding, and claim submission rules for vitamin D blood testing for Neighborhood Health Plan of Rhode Island members (Medicaid and Commercial). Applies to providers submitting claims for vitamin D testing.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVitamin D Testing Payment Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionOrder vitamin D testing only when clinical criteria are met and the test is medically necessary per referenced coverage sources.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2025INTEGRITY (MMP) effective

Jun 1, 2024Medicaid/Commercial effective

1-800-963-1001Provider Services

Coverage Criteria

Coverage when criteria met

Covered when clinical criteria from referenced sources are met and the test is medically necessary.

Medical necessity prerequisites: Test is covered only if medical necessity is met using one or more of: National Coverage Determination, Local Coverage Determination, industry accepted criteria such as InterQual, Rhode Island Executive Office of Health and Human Services recommendations, or clinical medical policies.

Specific qualifying diagnoses and other prerequisites are detailed in the full policy.

This summary does not list every qualifying diagnosis or explicit exclusion. The full policy contains the detailed list of specific diagnoses that qualify a member for vitamin D blood testing and any explicit exclusions. Providers must consult the full policy for the complete set of qualifying diagnoses and exclusion criteria that determine coverage.

Vitamin D testing that does not meet the policy's clinical criteria or otherwise be determined to be medically necessary is not covered. Medical necessity is determined using referenced authorities such as National Coverage Determinations, Local Coverage Determinations, industry-accepted criteria (e.g., InterQual), Rhode Island Executive Office of Health and Human Services recommendations, or clinical medical policies.

Covered Indications and Qualifying Diagnoses

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVitamin D Testing Payment Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionOrder vitamin D testing only when clinical criteria are met and the test is medically necessary per referenced coverage sources.

SourceLink

On This Page

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Covered indications — qualifying diagnoses

Providers must consult the full policy for the detailed list of qualifying diagnoses.

Qualified diagnoses: Specific diagnoses that qualify for vitamin D testing are described in the full policy and must be documented to support medical necessity.

See the full Neighborhood Vitamin D Testing Payment Policy for the complete list of covered indications and required documentation.

Codes and Coding Information

Codes and coding informationmixed

No codes listed

Coding (inventory)

Coding summaryNo procedure or diagnosis codes are listed in this summary; full policy includes coding information and claim submission instructions.

Code group statusCodes and coding information: 0 codes (neutral) per the brief.

Provider action for codesProviders must follow the full policy's coding and claim submission instructions when submitting vitamin D test claims.

Provider Actions and Requirements

Denial Risk

Medical necessity requirement

Vitamin D testing is covered only when the test is determined to be medically necessary and the member meets clinical criteria. Neighborhood may use National or Local Coverage Determinations, InterQual or other industry‑accepted criteria, Rhode Island Executive Office of Health and Human Services recommendations, and Neighborhood clinical medical policies to establish medical necessity.

Affected lines of business: INTEGRITY (MMP)
Policy effective for Medicaid and Commercial members: June 1, 2024

Prior Authorization

Provider requirements before ordering

Providers must follow the full policy to identify qualifying diagnoses and clinical prerequisites before ordering vitamin D testing. Review the policy for specific qualifying ICD‑10 diagnoses and clinical scenarios that justify testing.

If clinical criteria are not documented, the claim may be denied

Documentation Required

Documentation and claim submission

Providers must submit complete clinical documentation supporting medical necessity with the claim and follow the claim submission instructions and documentation requirements outlined in the full policy.

Include supporting diagnoses and rationale in the medical record and on claims
Contact Provider Services for questions: 1-800-963-1001

Denial Risk

Denial risk for unmet medical necessity

Claims for vitamin D testing that do not meet medical necessity criteria or lack adequate documentation are at risk for denial. Verify coverage criteria and retain documentation in the patient record to support medical necessity if audited.

Denial risk applies to requests not meeting National/Local Coverage Determinations, InterQual, RI EOHS guidance, or Neighborhood clinical policies

Ordering Requirements

Step Therapy

Ordering requirements and prerequisites

Ordering providers must follow the policy's prerequisites and documentation requirements when ordering vitamin D testing; the summary does not restrict who may order the test—consult the full policy for detailed ordering instructions and prerequisites.

Frequency Limits

Frequency limits

Frequency limits presentNo specific frequency limits are provided in this summary; the full policy contains any applicable limits.

Frequency applicabilityFrequency rules (if any) apply when clinical criteria and medical necessity are met as defined by the policy.

Provider responsibilityProviders should consult the full policy for exact test-specific frequency limits before ordering or billing.

Not Covered

Tests that do not meet the policy's medical necessity criteria are not covered. Claims for vitamin D blood testing may be denied when the clinical criteria and documentation required by the policy are not satisfied.

Vitamin D tests that fail to meet the clinical criteria and medical necessity requirements described in the policy are not covered. This statement is reiterated to make the not-covered rules readily visible to providers and billing staff.

Background

Neighborhood determines medical necessity for vitamin D testing using national and local coverage determinations and industry-accepted criteria (for example, InterQual), together with state-level guidance from the Rhode Island Executive Office of Health and Human Services and internal clinical medical policies. The policy became effective for Medicaid and Commercial members on June 1, 2024 and was updated to include the INTEGRITY (MMP) line of business effective January 1, 2025. Providers should follow the full policy for prerequisites, documentation, claim submission instructions, and the list of qualifying diagnoses; contact Provider Services at 1-800-963-1001 with questions.

Definitions

Medical necessity — definition and determination

Definition of medical necessityDetermination based on one or more of: National Coverage Determination (NCD), Local Coverage Determination (LCD), industry-accepted criteria such as InterQual, Rhode Island Executive Office of Health and Human Services recommendations, or clinical medical policies.

Practical effectVitamin D blood testing is considered a covered service only if clinical criteria are met and the test is determined to be medically necessary.

Documentation requirementProviders must follow the policy's documentation and claim submission instructions to demonstrate medical necessity and supporting diagnoses.

Where to find qualifying diagnosesSpecific diagnoses that qualify for testing are included in the full policy; providers should consult the full policy for details.