MassHealth Outpatient Physical Therapy prior authorization requirements (2026)
What MassHealth 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 MassHealth fee-for-service plans. Yes. MassHealth 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 MassHealth generally applies
Prior authorization is required for more than 20 physical-therapy visits (or 20 occupational-therapy visits, or 35 speech/language-therapy visits) per member within a 12-month period (130 CMR 433.408 / 403.417). Therapy must be prescribed by a physician, be medically necessary, and be recertified by the prescriber every 60 days. Comprehensive evaluations and reevaluations no longer require prior authorization and no longer count against the 20-visit allowance.
Commonly required documentation
- Physician prescription
- documentation of medical necessity
- 60-day prescriber recertification.
How to submit
- Method: MassHealth provider PA process (per provider manual Subchapter 5)
- Portal: MassHealth
Source
Source: 130 CMR 433.408 and 403.417; MassHealth Guidelines for Medical Necessity Determination for Physical Therapy. Last verified 2026-06-17.
Frequently asked questions
Does MassHealth require prior authorization for Outpatient Physical Therapy?
Yes. MassHealth 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 MassHealth require to approve Outpatient Physical Therapy?
Prior authorization is required for more than 20 physical-therapy visits (or 20 occupational-therapy visits, or 35 speech/language-therapy visits) per member within a 12-month period (130 CMR 433.408 / 403.417). Therapy must be prescribed by a physician, be medically necessary, and be recertified by the prescriber every 60 days. Comprehensive evaluations and reevaluations no longer require prior a… Always confirm against the current MassHealth policy.
How long does a MassHealth prior authorization take?
Turnaround varies by plan and submission method. Check the MassHealth portal for current timeframes.
Submitting Outpatient Physical Therapy to MassHealth?
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.