Prior authorization

Physical Therapy Prior Authorization: Requirements and Step-by-Step Process

Published 2026-10-06

Physical therapy prior authorization is a health plan's review of requested services before they are provided, when the plan requires that approval. To manage it, your clinic must determine which services require authorization, submit the right information, and keep treatment within the approved scope.

The patient's insurance company name alone does not answer those questions. Check the specific plan, provider, setting, services, and dates of care. An evaluation and the treatment that follows may have different requirements.

Use this guide to organize the work from the first insurance check through the last authorized visit. The steps below are a recommended clinic workflow; the patient's plan determines the actual submission and coverage requirements.

Eligibility, referral, and prior authorization are different checks

Check	What it establishes	What to resolve separately
Eligibility and benefits	Whether coverage is active and what the plan reports about therapy benefits, limits, and patient costs	Whether the scheduled services require authorization
Referral or order	Whether the required direction to care is in place	Whether the payer has approved the services
Prior authorization	The payer's determination on the requested services under its authorization process	Ongoing eligibility, available benefits, claim requirements, and patient responsibility

An insurance referral, a clinical order, and certification of a plan of care can also serve different purposes. Do not treat one document as satisfying every requirement.

Direct access rules address a patient's ability to receive physical therapist services under state law. They do not replace checking the patient's insurance requirements. APTA's direct access resources explain the state-law context.

Approval is not a guarantee of payment. HealthCare.gov's definition of preauthorization explicitly makes that distinction.

Step 1: Identify the patient's actual plan and the responsible reviewer

Start with current insurance information and verify coverage for the planned dates of service. Record the plan name and product, member information, and provider contact details in the clinic's approved system.

Determine whether the patient has commercial coverage, a Medicare Advantage plan, Original Medicare, or Medicaid coverage. For Medicaid, identify the state program and any managed care plan. For employer coverage, confirm the applicable benefit plan rather than relying only on the logo on the card.

If the patient has more than one plan, identify which is primary and which is secondary, and check each plan's authorization requirements. When the card shows Medicare, confirm whether the patient is in Original Medicare or enrolled in a Medicare Advantage plan. Original Medicare generally does not require prior authorization for outpatient physical therapy.

Then identify who handles outpatient physical therapy authorization. It may be the insurer, a delegated medical group, or a utilization management vendor. Confirm the submission destination before sending clinical records.

Use the member-specific provider portal, current authorization requirements, plan documents, and provider manual. If those sources conflict or do not answer the question, contact the responsible payer or reviewer. Save the response and reference number.

Step 2: Check the evaluation and treatment separately

Ask these questions for the planned services:

Is authorization required for the initial physical therapy evaluation?
Is treatment on the evaluation date subject to a separate requirement?
Must treatment be authorized before the first follow-up visit?
Does an authorization requirement begin after a visit threshold?
Does the requirement apply to the specific procedure codes and place of service?
Is notification or registration required even when clinical review is not?
Are there separate rules for a new episode, a new diagnosis, or a returning patient?

Document the answer, its source, and the date checked. If authorization is not required, record that result rather than leaving the field blank.

Ask about treatment on the evaluation date

An evaluation exemption does not necessarily apply to treatment delivered during the same appointment. Ask about both before the visit. Also distinguish “no clinical review” from “no authorization required.” A plan may still require a request even when it does not review the clinical records for that request.

UnitedHealthcare's outpatient therapy guidance illustrates these distinctions for its specified Medicare Advantage program. Use the current member-specific instructions rather than applying that example to every plan.

Step 3: Confirm benefits and authorization limits independently

Check the therapy benefit period, reported utilization, and any applicable limits. Ask whether a limit is shared across physical, occupational, or speech therapy, and whether treatment elsewhere affects the remaining benefit.

Keep the insurance benefit balance separate from the requested authorization. A request for additional authorized visits does not, by itself, create additional covered benefits.

Original Medicare's outpatient therapy rules also should not be described as a fixed annual visit allowance. Medicare states that there is no annual limit on payment for medically necessary outpatient therapy. Separate documentation and billing requirements still apply; an administrative threshold should not be mistaken for a fixed allowance of visits. For example, the 2026 KX modifier threshold is $2,480 in incurred expenses per beneficiary per year for physical therapy and speech-language pathology combined. Once a patient's incurred expenses for the year go above $2,480, the KX modifier must be added to the claim to confirm that the services are medically necessary, as supported by documentation in the medical record.

See Medicare physical therapy coverage and CMS Therapy Services.

Step 4: Assemble the administrative and clinical information

The authorization specialist or designated staff member should check the submission instructions and collect the required administrative information. This may include:

Member and plan identifiers.
Requesting and treating provider information, including the applicable NPI and tax ID.
Treatment location and place of service.
Requested services and procedure codes.
Diagnosis codes (ICD-10).
Proposed dates, visits or units, frequency, and duration.
Referral or order information when required.
Referring provider name and NPI, when required.
Existing authorization details if the request continues an episode of care.

The treating clinician supplies the clinical rationale. Depending on the payer's instructions, the packet may require an evaluation, plan of care, diagnosis, functional findings, goals, or other records supporting the requested treatment.

Check the payer's current documentation instructions rather than using a generic checklist as the final requirement. For a payer-specific reference, see UnitedHealthcare's outpatient therapy medical policy. Clinical coverage criteria and authorization submission requirements are separate questions.

Before submission, have staff check identifiers, attachments, signatures, requested quantities, and dates. Have the clinician check the clinical content. Administrative staff should not invent findings or modify the clinical rationale to fit an expected approval.

Step 5: Submit and save proof of receipt

Use the required portal, form, or other approved channel. Record:

Submission date and method.
Request or confirmation number.
Services, quantity, and dates requested.
Documents submitted.
Current status and assigned owner.
Next follow-up date.

Save the submission confirmation and a copy of the packet. “Submitted” does not mean “approved.” Check that the request was received and associated with the correct member and provider.

Avoid submitting a second request simply because the first is pending. Check its status and the payer's instructions first.

Step 6: Follow up using the applicable review timeframe

Use the plan's current rules to set the follow-up date. Check for requests for missing information, and route clinical questions to the treating therapist promptly.

There is no single turnaround time for every physical therapy authorization. Confirm the review timeframe for this request, whether anything is missing, and when your team should follow up. If a response is overdue, use the payer's escalation process and save the reference number. CMS's prior authorization guidance describes requirements for affected plans, but those rules do not apply uniformly to every insurer.

A nearby appointment does not by itself establish that a request qualifies for expedited review. Have the clinician assess urgency and follow the applicable criteria.

Step 7: Read and record the full determination

Do not stop at the authorization number. Check the determination against the original request and record:

Approved discipline and services.
Visits, units, or other quantity approved.
Effective and expiration dates.
Authorized provider and location, where specified.
Conditions, exclusions, or other limitations.
Any portion denied or approved for less than requested.

Ask for clarification if it is unclear whether the quantity includes the evaluation, whether the approval is cumulative, or whether a later approval replaces an earlier one.

A visit and a unit are not interchangeable. If an approval is expressed in units, track the authorized units using the payer's instructions and actual services rather than subtracting one for each appointment.

If the determination is adverse, use the physical therapy authorization denial guide.

Step 8: Connect the approval to scheduling and ongoing care

Give scheduling and clinical staff the usable result: what is approved, for which dates, how much remains, and if any data is pending. Name the person responsible for updating utilization.

Review completed services against the approval. Flag upcoming appointments that would fall after expiration or exceed the authorized quantity. Recheck requirements when the patient's plan changes or the planned services, provider, or location change.

Set follow-up triggers early enough to allow time for clinical documentation and payer review. Use the additional visits and authorization extension guide when care needs to continue.

Worked example: from evaluation to approved treatment

Fictional example. These quantities and dates are invented, not a payer policy.

A patient is scheduled for an evaluation on October 6. Staff confirm that the member's plan does not require authorization for the evaluation but does require it for follow-up treatment. They check treatment on the evaluation date separately.

After the evaluation, the therapist recommends eight treatment visits over four weeks. Staff submit the therapist's documentation with the required provider information and save the confirmation number.

The determination approves six treatment visits from October 8 through November 5. Staff record six approved visits, not the eight requested, and make the approved dates visible to scheduling.

After four completed treatment visits, two remain under this approval. The clinic reviews the therapist's recommendation and begins the applicable continuation process before scheduling care outside the existing approval. Staff also check the patient's remaining benefit separately.

Frequently asked questions

Does physical therapy always require prior authorization?

No. Verify the individual plan's requirements for the services, provider, setting, and dates. The evaluation and subsequent treatment may have different rules.

Who submits a physical therapy authorization request?

Confirm the responsible submitting provider under the plan's instructions. Within the clinic, administrative staff can coordinate submission and follow-up while the treating clinician supplies the clinical documentation.

What if the portal says authorization is not required?

Save the result, its date, and the member and service details used for the inquiry. Resolve any conflict with other applicable payer instructions before relying on it.

Can a clinic treat while authorization is pending?

Do not assume a pending request covers the service. Escalate the scheduling and clinical decision under the clinic's policy, the plan's rules, and applicable patient protections. A later determination does not automatically cover earlier dates.

Managing prior authorization across your physical therapy clinic

A complete request is only one part of the process. For a clinic owner or practice manager, the operating question is whether the work stays visible when staff change, appointments move, or a patient receives care at more than one location.

Assign an owner and backup for each stage: checking requirements, obtaining clinician documentation, submitting, monitoring responses, and updating the treatment record. Give scheduling access to the current determination and the pending questions. A handoff should identify the next action and responsible person, rather than relying on someone to remember to check a portal.

A simple handoff prevents repeat checking

Keep the latest answer in the clinic's existing patient record or approved work system. Include the request status, approved care, pending questions, owner, and next follow-up. When another staff member opens the record, they should be able to continue the work without repeating the original insurance check.

The therapist remains responsible for the clinical recommendation and documentation. Administrative staff coordinate the request and keep the answer visible to scheduling.

Keep the authorization record usable

Download the free prior authorization tracker to record requests, approved visits, effective dates, utilization, follow-up dates, and next actions. Its remaining-visit and expiration calculations support follow-up; the payer's actual determination remains the source of approval terms.

For help moving authorization work into your existing clinic workflow, explore Wiz's prior authorization service. If you are comparing software, read the separate prior authorization buyer's guide.

Research date: October 4, 2026.