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Credentialing for physical, occupational and speech-language therapists
Most of therapy credentialing is the same paperwork every other clinician faces: an individual NPI, state licensure, a complete CAQH profile, Medicare through PECOS, your state Medicaid program, then the commercial panels. Where therapists get stuck is in the handful of places the path forks, and the forks are rarely explained until an application bounces. This guide walks through each fork: Medicare's extra questions for therapists in private practice, what to do about assistants, the two kinds of Medicaid enrollment, and the delegated commercial networks that need their own applications.
Medicare: the same form, a few extra questions
Physical, occupational and speech-language therapists in private practice enroll on the same CMS-855I that physicians and nurse practitioners use, under their own supplier types. PTs and OTs answer an additional set of questions about where they treat: a private office you own or lease for the practice's exclusive use, patients' homes, or both, and a lease showing exclusive use is part of the file. Space shared with a physician practice, a gym or another therapy provider during your hours does not meet the exclusive-use standard and is a common reason for a development request.
Groups enroll on CMS-855B, and each therapist reassigns benefits to the group inside the same PECOS submission. One difference worth knowing in advance: physical therapists, individually and as groups, sit in Medicare's moderate screening category, which means an unannounced site visit is part of the process. The visit confirms the office exists, is open the hours you listed, and is equipped to treat. Have the signage up and the address on your application matching the door before you submit. Speech-language pathologists have been able to enroll in private practice since 2009 and are not in the moderate screening category.
Individual therapists and therapy groups do not pay the Medicare application fee that applies to institutional providers. What they do need is the CMS-588 EFT form, a current license in the state of the practice location, and, for a group, the Type 2 NPI and IRS documentation of the EIN.
Assistants are not enrolled, they are supervised
Physical therapist assistants and occupational therapy assistants cannot enroll with Medicare, CAQH, or the delegated therapy networks. Their services are billed under the supervising therapist, and the supervision rules are set by your state practice act as well as by Medicare. The enrollment question for assistants is therefore not how do we credential them but whether the supervising therapist is enrolled everywhere the assistant's work is billed.
There is a payment consequence to plan for. Since January 2022, outpatient therapy services furnished in whole or in part by a PTA or OTA are reported with the CQ or CO modifier and paid by Medicare at 85 percent of the fee schedule amount. Several commercial plans have adopted the same modifiers and the same reduction. A practice that leans on assistants should model that reduction into staffing decisions, and should confirm that every treating therapist, not just the owner, holds an active enrollment with every payer whose patients the assistant treats.
Medicaid: billing enrollment or ordering-only?
Under the 21st Century Cures Act every clinician who orders, prescribes or refers must be enrolled with the state Medicaid agency, and most states offer a streamlined ordering-and-referring enrollment for exactly that. It is quick, and it satisfies managed-care network requirements, but it does not authorize billing. Therapy practices that were enrolled under the Cures Act sometimes discover that their therapists cannot actually bill Medicaid fee-for-service. Before adding managed-care plans, confirm which kind of enrollment each therapist and the group actually holds.
Billing enrollment for therapists varies more by state than Medicare does. Some states enroll individual therapists and require a separate group enrollment; some enroll only the group and list therapists as rendering providers; some limit which therapy specialties bill fee-for-service at all and route the rest through managed care. Pediatric therapy adds another layer in states where school-based or early-intervention services run through a separate program with its own enrollment. PECS handles Medicaid enrollment at $500 per provider per state, half at engagement and half at approval.
Commercial panels: the networks nobody mentions
Several large commercial plans do not credential therapists directly. Their physical, occupational and speech therapy networks are delegated to a specialty vendor: Optum Physical Health for UnitedHealthcare and Oxford products, American Specialty Health for Cigna's physical and occupational therapy networks in many states, and those vendors run their own applications, their own primary-source verification and their own committee calendars, typically targeting around sixty days. A CAQH profile does not replace them. Other plans credential therapists in-house, some on a separate ancillary application per service location. Knowing which plan takes which route before the first application goes out is most of what separates a ninety-day project from a nine-month one.
The delegated networks also have their own contracting terms. Their fee schedules are separate from the plan's physician schedule, visit limits and authorization rules are set by the vendor, and some vendors tier providers based on outcomes reporting. Read the vendor agreement as carefully as you would read a plan contract, because it is the document that governs how you get paid for those members.
Blue Cross Blue Shield plans, Aetna and most regional plans credential therapists in-house, usually through CAQH. Some require a practice-level ancillary application in addition to the individual therapist file, and a few require a separate application for every service location. Each of these is a distinct application at $200 per application per provider.
What to have ready
Individual NPIs for every therapist and a Type 2 NPI for the group; state licenses with expiration dates; NBCOT or ASHA certification if you hold it (most payers do not require it, a few programs do); malpractice coverage, and some therapy networks want $1M per claim and $3M aggregate limits; a full five-year work history with month and year dates; a W-9 and lease or home-services statement for Medicare; and, for an existing group, the Medicare and Medicaid approval letters that show what is already in place.
- Type 1 NPI for each therapist, Type 2 NPI for the group
- State license for every state where you treat, with expiration dates
- Degree or transcript, plus NBCOT or ASHA certification where held
- Malpractice face sheet with limits, policy number and dates
- Complete, attested CAQH profile with each payer authorized
- Five-year work history and explanation of any gap
- Lease showing exclusive use, or a statement that services are furnished in patients' homes
- W-9, voided check and CMS-588 in the name of the billing entity
- Existing Medicare PTAN and Medicaid ID letters for a group that is adding a therapist
Adding a therapist to an existing group
The most common therapy credentialing project is not a new practice but a new hire. The group is already enrolled, so the work is to enroll the therapist individually where the payer requires it, reassign or link the therapist to the group, and add the therapist to each commercial and delegated network roster. Medicare handles this with a CMS-855I plus a reassignment; Medicaid varies by state; the delegated networks require a full individual application. Start this the day the offer letter is signed. A therapist who starts seeing patients before enrollment is complete generates claims that either deny or have to be held, and most commercial plans will not backdate an effective date to cover them.
What therapy credentialing costs
| Service | Price |
|---|---|
| CAQH profile, new build | $500 per provider |
| CAQH update and attestation | $250 |
| Medicare enrollment | $500 per provider, half at engagement and half at approval |
| Medicaid enrollment | $500 per provider per state, same split |
| Commercial or delegated network application | $200 per application per provider, same split |
| Availity setup | $250 |
| Group onboarding | $500 |
| Ongoing maintenance | $100 per provider per quarter |
Primary source verification is quoted separately when a network or facility requires it. Every application is followed up with the payer on a regular schedule, and the status of each one is visible by reference number at pecs.health/status.
Frequently asked questions
Can a physical therapist enroll in Medicare as a private practice?
Yes. Physical therapists in private practice enroll on CMS-855I through PECOS under their own supplier type, and a therapy group enrolls on CMS-855B with each therapist reassigning benefits to the group. PTs answer additional questions about where they treat, and Medicare expects a private office owned or leased for the practice's exclusive use, patients' homes, or both. Physical therapists are in the moderate screening category, so an unannounced site visit is part of enrollment.
Can PTAs and OTAs be credentialed with insurance?
No. Physical therapist assistants and occupational therapy assistants cannot enroll with Medicare, cannot hold a CAQH (now DataSpring) profile, and are not credentialed by the delegated therapy networks. Their services are billed under the supervising therapist within the supervision rules set by Medicare and your state practice act. Since 2022 Medicare pays outpatient therapy services furnished in whole or in part by a PTA or OTA, reported with the CQ or CO modifier, at 85 percent of the fee schedule amount.
Do therapists need a CAQH profile?
Yes for most commercial payers that credential therapists in-house, and some of the delegated networks also pull from it. The profile must be complete, attested, and authorized for each payer. A CAQH profile does not replace the separate applications that Optum Physical Health and American Specialty Health require for the networks they manage. PECS builds a new CAQH profile for $500 per provider and updates and attests an existing one for $250.
What is the difference between Medicaid billing enrollment and ordering-only enrollment?
Ordering, referring and prescribing enrollment satisfies the 21st Century Cures Act requirement and lets managed-care plans validate you, but it does not authorize you to bill Medicaid fee-for-service. Billing enrollment is a fuller application with a provider agreement and, in many states, a site or specialty review. Therapy practices that only hold ordering-only enrollment discover the gap when fee-for-service claims deny. Confirm which type each therapist and the group holds.
How long does therapy credentialing take?
Medicare typically takes 30 to 90 days after a complete application, longer if a site visit is scheduled. The delegated therapy networks typically target around 60 days from a complete file. Commercial plans that credential in-house typically take 60 to 120 days to a signed contract. Because the delegated networks run on their own calendars, submitting them at the same time as Medicare and Medicaid, not after, is what keeps a project near 90 days rather than nine months.
Does Cigna credential physical therapists directly?
In many states Cigna's physical and occupational therapy networks are delegated to American Specialty Health, which runs its own application, primary source verification and committee review. In those states applying to Cigna directly gets you redirected. UnitedHealthcare and Oxford therapy networks are similarly delegated to Optum Physical Health. Which route applies depends on the state and the product, and confirming it before the first application is a normal part of intake.
Can a speech-language pathologist bill Medicare in private practice?
Yes. Speech-language pathologists have been able to enroll in Medicare as private practitioners since 2009 and enroll on the same CMS-855I as PTs and OTs under their own supplier type. SLPs do not face the moderate screening site visit that applies to physical therapists. State licensure is required, and ASHA certification is accepted by payers as evidence of qualification but most do not require it.
What does PECS charge for therapy credentialing?
Pricing is flat and published. CAQH new build is $500 per provider, CAQH update and attestation is $250, Medicare enrollment is $500 per provider, Medicaid enrollment is $500 per provider per state, and commercial and delegated network applications are $200 per application per provider. Medicare, Medicaid and commercial fees are billed half at engagement and half at approval. Group onboarding is $500 and ongoing maintenance is $100 per provider per quarter.
Answers cover PECS services, prices and process. For legal, tax or clinical questions please consult a professional.
By the PECS credentialing team, updated September 23, 2026.