It didn’t hit me until I tried to schedule a second month of visits: the clinical plan and the insurance plan do not always speak the same language. My therapist mapped out goals and progress markers; my insurer talked about “units,” “medical necessity,” and “prior authorization.” Somewhere between the balance board and the billing codes, I realized I needed a simple way to track what’s actually covered, when I need permission first, and how to avoid surprise denials. So I wrote down everything I wish I’d known before I started.
The moment I realized paperwork can shape recovery
My aha moment came when the front desk asked whether I had “authorization on file” for the new plan of care. I remember feeling annoyed—wasn’t my doctor’s referral enough? It turns out a referral (a clinician’s nudge to start PT) isn’t the same as prior authorization (an insurer’s approval for payment). Once I separated those ideas, the whole process felt less mysterious. A high-value takeaway I keep pinned in my notes: authorization is about payment, not permission to take care of your body. You and your therapist can decide what’s clinically right, and then you decide what to do financially if the plan and the insurer disagree.
- Ask early if your plan requires prior authorization for PT/OT/Speech therapy. Some plans do, some don’t. Medicare Advantage plans may use it more often than Original Medicare, while many marketplace and employer plans apply it selectively.
- Confirm whether you have a visit limit (e.g., 20–60 visits/year), a unit limit per day, or a modality limit (certain procedures only X times). Visit limits are benefit-related; medical necessity is clinical—both matter.
- Bookmark at least one reliable explainer. For example, see physical therapy coverage basics at Medicare.gov and the essential health benefits overview for rehab at HealthCare.gov.
How I map the moving parts without getting overwhelmed
I made myself a one-page grid: “What I want to do” versus “What my plan recognizes.” On the left, I list goals—walk 30 minutes without pain, lift my toddler, return to tennis. On the right, I translate that into covered services and billing codes. That second column is nerdy, but it’s where the coverage limits live. It’s also where I keep links to neutral sources like APTA’s patient pages in case I need an impartial explanation of terms.
- Benefit design: Is PT a separate copay per visit, coinsurance after deductible, or bundled with an annual visit cap?
- Authorization rules: Which services need approval before the first session? Are extensions allowed if you’re progressing? Who submits—clinic or you?
- Clinical documentation: What “medical necessity” looks like in paperwork (clear diagnosis, functional goals, measurable change).
When I first saw an “EOB” (Explanation of Benefits), I learned to ignore the scary not a bill formatting and scan for three lines: what was billed (codes/units), what the plan allowed (the negotiated amount), and what I owe (copay/coinsurance/deductible). If the allowed amount was $0 because authorization was missing, I knew exactly why the claim bounced—and what to fix.
Visit caps versus medical necessity and why it matters
Two levers affect payment: benefit limits (the plan’s maximums) and medical necessity (documentation that therapy is reasonable and needed). Both can be true at once: you may still have visits left, but the insurer can deny if notes don’t show progress; or your progress is great but you’ve hit the plan’s cap. Marketplace plans categorize rehab and habilitation as “essential health benefits,” but specifics—like the number of covered visits or how prior authorization works—are decided at the plan level and often by state benchmarks (see the overview at HealthCare.gov).
- Visit caps: e.g., 30 PT visits/year combined with OT. Some plans count each date of service; others count by unit thresholds.
- Medical necessity: Insurers look for objective measures (ROM, strength grades, gait speed), functional goals tied to daily life, and steady or expected progress.
- Exceptions/Extensions: Many plans allow extra visits if you meet criteria and the clinic submits updated notes. This often requires prior authorization or a re-authorization.
Medicare is a helpful contrast. Original Medicare does not use a preset nationwide visit cap for outpatient therapy. Instead, it expects services to be medically necessary and may require extra justification once you cross certain yearly cost thresholds. Medicare Advantage plans can add prior authorization layers, though they still must follow Medicare coverage rules. If you’re on Medicare and confused, the plain-language page at Medicare.gov is the most practical starting point.
Prior authorization decoded in plain language
“Prior auth” is essentially the insurer asking for the story before it agrees to pay. For therapy, it usually means submitting your diagnosis, planned frequency/duration, and goals. It can feel redundant, but it’s how they make sure the benefit fits the clinical case. Consumer regulators like the National Association of Insurance Commissioners (NAIC) publish primers that explain timelines and appeal rights without jargon (see NAIC’s consumer materials here).
- Who requests it: Most clinics will submit on your behalf. You can absolutely ask to see what they send.
- When to request: Before starting therapy or before exceeding a preset number of visits. Some plans auto-authorize first few visits.
- What to include: Clear diagnosis, objective baselines, functional goals, evidence-based plan of care, and expected timeline.
One more nuance: “referral required” and “prior authorization required” can both appear in your Summary of Benefits and Coverage (SBC). The SBC is a standardized, short document your employer or insurer must provide (see the U.S. Department of Labor’s guide to SBCs here). A referral is your clinician’s note saying “PT makes sense.” Authorization is the plan’s prepayment approval. You might need one, both, or neither—depending on your plan.
How I prepare for a new episode of care
Before the first visit, I do a five-minute check. It saves so much friction later and helps the therapist’s admin team help me.
- Call the number on your card and ask, “Do I need prior authorization for outpatient physical therapy? Are there annual visit limits? What are my copay or coinsurance amounts after deductible?”
- Ask about place of service: Coverage can differ between a hospital outpatient department and a free-standing clinic.
- Confirm network status: Out-of-network benefits often have separate deductibles and lower coverage. In network reduces surprises.
- Bring your goals: Share real-life targets (“carry groceries up my stairs”)—they anchor medical necessity and progress notes.
- Request a copy of the authorization once approved. Clinics will usually share the authorization number and dates.
Why documentation style affects approvals
I used to think therapy notes were just for internal use. They’re actually the backbone of coverage. Approvals tend to go more smoothly when notes connect the dots between baseline deficit, chosen interventions, and measured change. The American Physical Therapy Association’s patient resources are great for understanding why a therapist might choose manual therapy, therapeutic exercise, or neuromuscular re-education in a given week (APTA patient care).
- Baseline: “Hip abduction 3/5, single-leg stance 6 seconds, pain 6/10 with stairs.”
- Plan: “Therapeutic exercise 97110, neuromuscular re-ed 97112, home program 3x/week.”
- Progress: “Single-leg stance now 18 seconds; able to carry 10 lb up flight with moderate pain; FOTO score improved.”
If your plan ever asks for “additional information,” this is what they’re trying to see. You’re allowed to ask your clinic how they document progress and how extension requests are framed.
When a denial shows up and what I actually do
My first denial came labeled “authorization missing.” The clinic had submitted, but the payer’s portal didn’t match the diagnosis code. We appealed with an updated letter of medical necessity and a corrected code. It was overturned. What I learned: denials are not final decisions. Every plan has an appeal route and timelines. Many marketplaces and employer plans follow state and federal standards for internal and external review. NAIC’s consumer pages summarize the steps neutrally (NAIC consumer resources).
- Check the denial reason: missing authorization, medical necessity not met, benefit limit reached, or coding mismatch.
- Ask the clinic to submit a reconsideration: updated notes, objective data, and a short letter framing the functional need.
- Use timelines: Appeals have windows—mark them on your calendar and set reminders.
Hidden traps I watch for so I don’t blow my budget
The surprise costs usually come from the benefit design, not the therapist’s plan. I’ve been burned by deductibles resetting, by hospital-affiliated clinic fees, and by out-of-network claims that looked in-network on a website directory. Now I use a simple checklist.
- Deductible status: Where am I in the year? January visits can cost more out of pocket.
- Site-of-service charges: Hospital outpatient departments may have facility fees. Ask what applies to your plan.
- Telehealth: Covered broadly during public health emergencies and still covered by many plans, but rules vary post-emergency. Confirm before you rely on it.
- Home exercise programs: Usually included and not separately billed; still, ask how your plan treats remote coaching or digital tools.
For marketplace plan specifics, the essential health benefits page is my go-to starting map (HealthCare.gov). And for Medicare questions, I always cross-check the simple language page at Medicare.gov before asking a clinic to submit anything new.
Special cases that change the rules
Not all PT is billed the same way. I learned this the hard way when a friend’s work injury went through a completely different channel.
- Workers’ compensation: Separate authorization processes and fee schedules. Your employer or state comp carrier sets the rules; your health plan usually won’t pay for the same injury.
- Auto injury (PIP/MedPay): These can be primary payers in auto accidents. Coordination of benefits matters—tell your PT clinic early.
- School-based or early intervention services: Different funding streams than health insurance, especially for children; ask the program coordinator, not your insurer.
- Medicaid: State-specific rules on visit limits and prior auth. Your state Medicaid website is the authority; some states are very generous, others more structured.
My practical script for calling the insurer
Calling member services is a skill. I now treat it like a mini-interview. I have a pen, my member ID, and my therapist’s NPI if possible. Then I use a script that keeps me on track.
- “Can you confirm if outpatient physical therapy requires prior authorization on my plan?”
- “What is my annual limit for PT and OT, and do they combine?”
- “What are my out-of-pocket costs per visit after the deductible?”
- “Does coverage change if I go to a hospital outpatient department instead of a free-standing clinic?”
- “Where can I download my Summary of Benefits and Coverage?” (Find the SBC explanation at the Department of Labor here.)
How I keep my notes so I can prove what happened
Insurance is a paper sport. I keep a single page with dates, names, and numbers, because if I need to appeal later, this becomes gold.
- Date, time, and the name/ID of the person I spoke with.
- Exactly what they said about authorization, limits, and costs.
- Authorization numbers, effective dates, and any case/claim IDs.
- Copies of EOBs and clinic letters of medical necessity.
Most denials I’ve seen resolve when the story is clear and the paperwork matches. Clinicians appreciate when patients keep clean records—everyone saves cycles.
The mindset that keeps me steady when rules feel arbitrary
When I catch myself spiraling—“Why is this so complicated?”—I come back to three principles I can control:
- Clarity beats assumptions: If I don’t know, I ask. One five-minute call can prevent weeks of billing back-and-forth.
- Progress is a story: Objective notes plus real-life wins (“I can walk the dog again”) are powerful for both care and coverage.
- Appeal is part of the process: A “no” is often a “not yet” pending the right documentation.
For neutral, non-salesy refreshers, I lean on official sites: Medicare.gov for Medicare basics, HealthCare.gov for marketplace benefits, APTA for therapy explanations, and regulator pages like NAIC for appeal timelines.
FAQ
1) Do I always need prior authorization for physical therapy?
Answer: No. It depends on your plan. Original Medicare generally focuses on medical necessity and documentation rather than up-front prior auth, while many employer and marketplace plans use prior auth selectively. Medicare Advantage plans often require it. Check your plan’s SBC or call member services; you can preview the SBC concept via the U.S. Department of Labor’s page here.
2) My plan says I have 30 visits. What if I need more?
Answer: Many plans allow extensions if you’re improving and the therapist documents why more visits are reasonable. This often means a re-authorization. Your clinic can submit updated goals and progress. If denied, use the plan’s appeal process—consumer resources from NAIC outline the steps.
3) Is a doctor’s referral the same as authorization?
Answer: No. A referral is clinical; authorization is financial approval from the plan. Some plans require both, others require neither. Many states allow direct access to a physical therapist without a physician referral for at least an evaluation; see patient-friendly info at APTA.
4) How do I know what I’ll pay per visit?
Answer: Look for copay versus coinsurance after deductible in your SBC and provider directory. Costs can also depend on the site of service (hospital outpatient vs. clinic). For marketplace specifics, the essential health benefits summary at HealthCare.gov helps frame what’s typically covered.
5) What should be in a strong letter of medical necessity?
Answer: A clear diagnosis, functional goals tied to daily activities, objective baselines (range of motion, strength, balance), and documented progress over time. If an extension is requested, it should explain why additional visits are expected to help. For Medicare-oriented language, the plain guide at Medicare.gov is a good reference.
Sources & References
- Medicare.gov — Physical therapy coverage
- HealthCare.gov — Essential health benefits
- APTA — Patient care resources
- NAIC — Consumer resources on appeals and authorizations
- U.S. Department of Labor — Summary of Benefits and Coverage
This blog is a personal journal and for general information only. It is not a substitute for professional medical advice, diagnosis, or treatment, and it does not create a doctor–patient relationship. Always seek the advice of a licensed clinician for questions about your health. If you may be experiencing an emergency, call your local emergency number immediately (e.g., 911 [US], 119).