Healthfirst Outpatient Physical Therapy prior authorization requirements (2026)
What Healthfirst generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Medicaid plans. Yes. Healthfirst generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Healthfirst generally applies
The initial PT evaluation does not require prior authorization; prior authorization is required for therapy beyond the allowable units. A provider questionnaire accompanies initial adult PT authorization requests to support the clinical review, and select CPT codes are managed by eviCore under evidence-based guidelines. Continued therapy is supported by a skilled plan of care with measurable functional goals and documented progress, or maintenance therapy to prevent decline where covered. Applies across Healthfirst Medicaid, Medicare, Essential, and QHP plans. Verify the member plan and the current eviCore/Healthfirst guideline.
Source
Source: Healthfirst Provider PT Authorization and Approval Guidance and eviCore by Evernorth Healthfirst program (hfproviders.org). Last verified 2026-06-11.
Frequently asked questions
Does Healthfirst require prior authorization for Outpatient Physical Therapy?
Yes. Healthfirst generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Healthfirst require to approve Outpatient Physical Therapy?
The initial PT evaluation does not require prior authorization; prior authorization is required for therapy beyond the allowable units. A provider questionnaire accompanies initial adult PT authorization requests to support the clinical review, and select CPT codes are managed by eviCore under evidence-based guidelines. Continued therapy is supported by a skilled plan of care with measurable funct… Always confirm against the current Healthfirst policy.
How long does a Healthfirst prior authorization take?
Turnaround varies by plan and submission method. Check the Healthfirst portal for current timeframes.
Submitting Outpatient Physical Therapy to Healthfirst?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.