Prior authorization is your insurer’s advance decision that a set number of physical therapy visits is medically necessary, made before those visits happen. The therapist’s office usually sends the evaluation findings and plan of care to the insurer, which approves a number of visits over a date range, asks for more information or denies the request. Approval is not a promise of payment, and it is separate from a referral and from Indiana’s 42-day direct access law. Original Medicare does not generally require it for outpatient therapy, while many Medicare Advantage, Medicaid managed care and commercial plans do.
Last reviewed By the Monon Therapy Collective editorial team
How is prior authorization different from a referral?
A referral is a provider’s recommendation that you see a physical therapist; prior authorization is the insurer’s approval to pay for the visits. You can need one, both or neither. Indiana law lets a physical therapist evaluate and treat you without a referral for up to 42 calendar days, but that law governs the therapist’s license, not your insurance contract.
So a plan can still ask for an authorization number even when you went straight to a therapist, and an HMO can ask for a referral as well. HealthCare.gov’s definition adds a caution worth remembering: preauthorization is not a promise your plan will cover the cost, because eligibility, deductibles and the final claim still apply. Our referral rules for Indiana page covers the legal side in full.
Which insurance plans ask for prior authorization before therapy?
Requirements are set plan by plan, so the only reliable answer comes from your own plan. As a general pattern, Original Medicare does not require advance approval for outpatient physical therapy, while Medicare Advantage plans, Medicaid managed care plans and many commercial plans do use it, often through a separate company that reviews therapy requests for the insurer.
Many plans let the evaluation happen without approval and require authorization for the treatment visits that follow. Others approve an initial block and ask for a fresh request with progress notes to continue. If you are covered through Indiana Medicaid or the Healthy Indiana Plan, the rules come from your managed care plan, which the Healthy Indiana Plan physical therapy page explains.
What does the prior authorization process look like from start to finish?
In most practices the therapist’s office runs the process, and your job is mostly to share accurate insurance details and keep your appointment dates. The steps below are typical; your plan may add or skip one.
- The therapist’s office checks your benefits and learns whether authorization is required, and from which date.
- You attend the evaluation, where the therapist measures your movement, strength and function and sets goals.
- The office submits the evaluation, the diagnosis codes and the proposed plan of care to the insurer or its review company.
- The insurer approves a number of visits within a date range, asks for more records, or denies the request with a reason.
- Before the approved visits or dates run out, the office sends progress notes to request more if care is still needed.
How long does an insurer take to approve physical therapy visits?
Under a federal rule that took effect for 2026, Medicare Advantage plans, Medicaid and CHIP programs and their managed care plans must decide standard prior authorization requests within seven calendar days and urgent ones within 72 hours. They must also give a specific reason when they deny a request. Plans sold on the federal marketplace are not covered by those deadlines, and employer plans follow their own timelines under other rules.
In practice, a complete request moves faster than a thin one. The most common delay is missing information, such as an evaluation without measurable goals. If your first visit falls before approval arrives, ask the therapist’s office whether that visit is protected; scheduling the evaluation first and treatment visits after approval is a common way to avoid paying for an unapproved session.
What can I do if my physical therapy authorization is denied?
Ask why first, because many denials are fixable paperwork problems. The therapist can often request a peer-to-peer conversation with the insurer’s reviewer, send missing measurements or resubmit with a clearer plan. If the denial stands, you have the right to an internal appeal, which you generally must file within 180 days of the denial notice.
For a service you have not received yet, the plan must usually decide an internal appeal within 30 days. If it still says no, you can ask for an external review by an independent third party, so the insurer no longer has the final word. Paying privately while you wait is an option; the self-pay physical therapy page explains how that works with therapists in the network.
Related questions
Who requests prior authorization, me or the therapist?
Almost always the therapist’s office, because the insurer wants clinical records only the therapist has. You help by giving correct plan details and telling the office about any visits you have already used this year.
Does an approved authorization mean my visits are free?
No. It means the plan agreed the visits are medically necessary. Your deductible, copay or coinsurance still apply, and the claim can still be denied for reasons such as lapsed coverage.
What happens if I go to physical therapy before approval comes through?
The plan may refuse to pay for visits outside an approved date range, leaving you responsible. Ask the office before each early visit whether it is covered.
Do I need a new prior authorization after surgery?
Often yes, because post-surgical rehab is a new episode of care. The surgeon’s order and operative details usually go with the request.
Does the matching team handle my authorization?
No. The matching team proposes a therapist in the network whose office works with your plan where possible, and that office verifies benefits and handles any authorization.
Does prior authorization expire?
Yes. Approvals usually cover a set number of visits within a date range, and unused visits lapse when the range ends. If your schedule slips, ask the office to request an extension before the end date.
Keep reading
- Do I need a referral for physical therapy with an HMO?
- How many physical therapy visits does insurance cover?
- What is a physical therapy plan of care?
- How benefits are checked before your first visit
- Medicare Advantage and physical therapy
- Tell the matching team about your plan
Sources
This page is general education, not medical advice. A physical therapist can only advise on your situation after an examination.
