CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vitamin D Testing Payment Policy

Defines medical necessity criteria and prerequisites for coverage of vitamin D blood testing for Neighborhood Health Plan of Rhode Island Medicaid and Commercial members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVitamin D Testing Payment Policy

Policy CodePolicy N/A

Change TypeNew policy (added)

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionDocument clinical criteria and medical necessity when ordering vitamin D blood testing to support coverage.

SourceLink

POLICY UPDATE CHANGES

A new Vitamin D Testing Payment Policy will make vitamin D blood testing covered only when clinical criteria are met and the test is determined to be medically necessary.

Jun 1, 2024policy effective date

Apr 1, 2024announcement date

2member populations covered

Coverage and Medical Necessity

Coverage when medical necessity met

Covered only when medical necessity criteria are met

General medical necessity: Vitamin D blood testing is covered when clinical criteria are met and the test is determined to be medically necessary using National Coverage Determination, Local Coverage Determination, industry accepted criteria (eg InterQual), Rhode Island Executive Office recommendations, and Neighborhood Clinical Medical Policies.

Providers should consult the policy for specific qualifying diagnoses and documentation requirements.

Tests that do not meet the policy's stated clinical criteria or that lack documented medical necessity are not covered. Effective June 1, 2024, vitamin D blood testing will only be considered a covered service when the clinical criteria are met and the test is determined to be medically necessary for Medicaid and Commercial members.

Specifically, vitamin D blood testing that does not meet the policy's clinical criteria and does not have a documented medical necessity determination will not be considered a covered service. Providers should review the policy's qualifying diagnoses and documentation requirements before submitting claims.

Qualifying Diagnoses and Indications

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVitamin D Testing Payment Policy

Policy CodePolicy N/A

Change TypeNew policy (added)

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionDocument clinical criteria and medical necessity when ordering vitamin D blood testing to support coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Specific qualifying diagnoses as detailed in the full policy

Providers should review the policy for the list of specific diagnoses that qualify for testing.

Covered indications: Specific qualifying diagnoses are detailed in the full policy; providers must document a qualifying diagnosis to support medical necessity for vitamin D blood testing.

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

Coding and Billing

Coding information referencedmixed

No codes listed

Coding (inventory)

Coding summaryNo specific CPT/HCPCS or diagnosis codes listed in this policy summary; coding information is referenced in the full policy for claim submission.

Coding statusCoding information referenced (neutral) — providers should consult the policy's coding section for exact codes.

Coding systemsPolicy references mixed coding systems (procedure and diagnosis codes) to be used per claim submission instructions.

Where to find codesSee the full policy's CODING section for detailed code lists and claim submission guidance.

Provider Responsibilities and Billing Actions

Prior Authorization

Action Required for Providers

Effective June 1, 2024, vitamin D blood testing will only be considered a covered service if clinical criteria are met and the test is determined to be medically necessary. Providers must document medical necessity and follow the payer's claim submission and documentation requirements to support coverage decisions. Claims for vitamin D testing may be denied if clinical criteria are not met or medical necessity is not established.

Medical necessity requirement: Vitamin D blood testing is covered only when clinical criteria and medical necessity are documented per the payer's policy. Neighborhood may reference National and Local Coverage Determinations, InterQual or similar industry-accepted criteria, RI Executive Office of Health and Human Services recommendations, and internal Clinical Medical Policies when determining eligibility.
Documentation requirements: Providers must include diagnostic information and supporting clinical rationale with claims per the policy's claim submission instructions. Maintain and submit clinical records demonstrating that testing meets the specified criteria.
Denial risk: Claims for vitamin D testing that lack documentation of medical necessity or do not meet the clinical criteria may be denied.
Provider action: Review the full Vitamin D Testing Payment Policy for the list of qualifying diagnoses, coding guidance, and submission instructions. Contact Provider Services at 1-800-963-1001 with questions.

Ordering and Submission Requirements

Step Therapy

Ordering requirements for Medicaid and Commercial members

Applies to tests ordered for Medicaid and Commercial members; providers should follow Neighborhood's policy documentation and submission instructions when ordering vitamin D testing.

This policy is effective June 1, 2024 and applies to both Medicaid and Commercial members.

Non-covered Services

Not covered: Vitamin D testing without clinical criteria or documented medical necessity. Neighborhood will deny or not consider such testing a covered service unless the requirements set forth in the policy are satisfied.

Test Frequency and Limits

Frequency limits (inventory)

Frequency rule presentNo specific frequency limits specified in the summary; full policy should be consulted for any test-specific intervals or limits.

Applies toMedicaid and Commercial members subject to the policy effective June 1, 2024.

Provider actionFollow the policy's documentation and claim submission instructions to determine allowable testing frequency.

Where documentedFrequency limits (if any) are located in the laboratory frequency limits section of the full policy.

Definitions and Terminology

Medical necessity (definition)

DefinitionMedical necessity determination: assessment based on National Coverage Determination, Local Coverage Determination, industry criteria (e.g., InterQual), Rhode Island Executive Office recommendations, and Neighborhood Clinical Medical Policies.

Decision basisNeighborhood may use national and local coverage determinations, industry-accepted criteria, state recommendations, and its clinical policies to determine medical necessity for vitamin D testing.

Documentation requirementProviders must follow the policy's claim submission instructions and documentation requirements to support medical necessity determinations.

Coverage implicationVitamin D testing is covered only when clinical criteria are met and the test is determined to be medically necessary; tests not meeting criteria are not covered.

Background and Evidence Basis

Neighborhood will determine medical necessity using national and local policy sources and industry-accepted criteria. These include National Coverage Determination, Local Coverage Determination, industry-accepted criteria such as InterQual, recommendations from the Rhode Island Executive Office of Health and Human Services, and Neighborhood's Clinical Medical Policies. The policy provides specific qualifying diagnoses and documentation instructions to help providers establish eligibility for vitamin D testing.