Resources

Opening a PT Private Practice: The Insurance Checklist

A new outpatient physical therapy practice gets in network in a fixed order: business identity first, then each therapist's credentials, then Medicare, Medicaid and the commercial plans, filed close together. The steps below are the generic sequence for a practice billing under its own Tax ID. Skipping ahead is what produces rejections, because every payer cross-checks the same names, numbers and address.

1. Business Identity

• Entity. Form the LLC, PLLC or professional corporation your state allows for physical therapists. Confirm with your state board or attorney.
• EIN. Get the EIN from the IRS and keep the confirmation letter; its legal name is the one every payer will match.
• Group NPI. Get the practice's Type 2 NPI in NPPES with a physical therapy taxonomy and the practice address.
• Bank account and W-9 in the entity's name, for electronic payment enrollment.

2. Each Therapist

• Individual NPI with the physical therapist taxonomy (225100000X), and the practice location updated in NPPES.
• State PT license active in the state of the practice location, with the expiration date on file.
• Malpractice naming the practice and each therapist as the payers require. Some therapy networks set minimum limits higher than a new practice may carry, so check before you buy the policy.
• CAQH (DataSpring) profile for each therapist, listing the practice location and Tax ID exactly as on the W-9, attested, and authorized for each plan.

3. Medicare

The practice enrolls on CMS-855B as a physical therapy group in private practice, and each therapist files one CMS-855I that also reassigns benefits to the group, since CMS merged the old 855R into the 855I in 2023. A therapist in private practice must treat in office space the practice owns, leases or rents and uses exclusively for the practice when treating there, or in patients' homes; the 855I asks about it and a lease showing exclusive use goes in the file. Physical therapists, as individuals and as groups, are in Medicare's moderate screening category, which adds an unannounced site visit. File the CMS-588 for electronic payment with the application.

4. Location Readiness

Time the filings to the opening. The Medicare contractor can return an application received more than 60 days before the effective date listed on it, and the site visit confirms the office is open, staffed during posted hours and equipped to treat. Medicare allows billing back only 30 days before the effective date, and only when every requirement was met. Commercial plans and Medicaid programs set their own rules on credentialing an address that is not open yet, and some will not accept one, so ask each payer before you submit.

5. Availity and the Commercial Plans

• Availity Essentials: register the practice, with someone at the practice as the primary administrator. Several plans, including Aetna, Humana and many Blue plans, route enrollment status and claims through it.
• Your state's Blue plan: usually credentials therapists in house through CAQH (DataSpring). Some require a practice-level ancillary application, and a few require one per service location.
• Aetna: submit the request to join; after contracting Aetna pulls the application from CAQH (DataSpring), so authorize Aetna in the profile.
• UnitedHealthcare and Oxford: outpatient therapy goes to Optum Physical Health, which handles credentialing and contracting for UnitedHealthcare. Start with a Letter of Interest at MyOptumHealthPhysicalHealth.com or 800-873-4575.
• Cigna: in many states PT and OT go through American Specialty Health, which runs its own application. See the PT, OT and speech credentialing guide.

6. Medicaid

Enroll with the state Medicaid program first, then with each Medicaid managed care plan. Confirm you are filing a billing enrollment, not an ordering and referring enrollment, which does not authorize fee-for-service billing. States differ on whether therapists enroll individually, as a group, or both.

Keep Every Record Identical

The legal name, Tax ID, NPI and practice address must read the same in NPPES, the IRS letter, the W-9, each CAQH (DataSpring) profile and every application, down to the suite number. A mismatch between IRS records and an application is one of the most common reasons Medicare rejects a file, and commercial plans stop on the same mismatches.

Pre-Submission Checklist

1. Entity documents, IRS EIN letter and W-9 with the same legal name
2. Type 2 NPI and each therapist's Type 1 NPI with the correct taxonomy and practice address
3. Active PT license for each therapist in the practice state
4. Malpractice certificate naming the right insureds, with limits each network accepts
5. Lease showing exclusive use, signage up and hours posted
6. Each CAQH (DataSpring) profile complete, attested and authorized
7. CMS I&A roles and any surrogate approved; CMS-588 and voided check ready
8. Opening date confirmed against each payer's rule on future locations

PECS handles the full sequence at the flat prices on our pricing page, and our therapy group practice guide covers adding therapists later. Published PT rates by state and insurer are on physical therapy insurance rates.

Frequently Asked Questions

Sources: 42 CFR 410.60 (PT in private practice) · 42 CFR 424.518 (screening levels) · 42 CFR 424.526 (returned applications) · 42 CFR 424.521 (retrospective billing) · CMS: consolidated CMS-855I and 855R · UnitedHealthcare: Optum Physical Health · Aetna: join the network.

By the PECS credentialing team. Updated October 2026.