Mass General Brigham Health Plan Outpatient Physical Therapy prior authorization requirements (2026)
What Mass General Brigham Health Plan 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 Commercial: no PA; MGB ACO/MassHealth: eval no PA, subsequent visits require PA plans. Based on the cited policy, Mass General Brigham Health Plan does not generally require 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). Confirm with Mass General Brigham Health Plan, as this can vary by plan.
Medical-necessity criteria Mass General Brigham Health Plan generally applies
For Commercial members, outpatient physical therapy does not require prior authorization (subject to plan visit limits; see MGBHP Medical Policy: Definition of Skilled Care). For Mass General Brigham ACO/MassHealth members, the initial evaluation does not require prior authorization but subsequent visits do.
Commonly required documentation
- Evaluation and plan of care
- for ACO/MassHealth subsequent visits, documentation supporting continued medical necessity.
How to submit
- Method: Mass General Brigham Health Plan provider portal
- Portal: MGBHP Provider Portal
Source
Source: MGBHP Prior Authorization, Notification, and Referral Guidelines. requires_prior_auth=false reflects the commercial posture. Last verified 2026-06-17.
Frequently asked questions
Does Mass General Brigham Health Plan require prior authorization for Outpatient Physical Therapy?
Based on the cited policy, Mass General Brigham Health Plan does not generally require 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). Confirm with Mass General Brigham Health Plan, as this can vary by plan.
What does Mass General Brigham Health Plan require to approve Outpatient Physical Therapy?
For Commercial members, outpatient physical therapy does not require prior authorization (subject to plan visit limits; see MGBHP Medical Policy: Definition of Skilled Care). For Mass General Brigham ACO/MassHealth members, the initial evaluation does not require prior authorization but subsequent visits do. Always confirm against the current Mass General Brigham Health Plan policy.
How long does a Mass General Brigham Health Plan prior authorization take?
Turnaround varies by plan and submission method. Check the Mass General Brigham Health Plan portal for current timeframes.
Submitting Outpatient Physical Therapy to Mass General Brigham Health Plan?
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.