How to become a Medicaid therapy provider

For OT, PT and SLP practices treating children, adults or both: you become a Medicaid provider by enrolling with your state Medicaid agency, which screens you under federal rules, and by contracting separately with each Medicaid managed care plan you want to join. State enrollment, plan contracts, prior authorization and payment are separate steps.⁠^1,2

Who enrolls a therapy practice in Medicaid, the state or CMS?

Your state Medicaid agency does. The agency must screen every provider it enrolls under the federal rules in 42 CFR part 455, subpart E, and those rules set a floor: a state may add screening methods of its own that are more stringent.⁠^1,14 There is no single national Medicaid application, so the forms, the portal, the provider types and the manual are your state’s.

The state does not have to repeat work already done elsewhere. It may rely on the results of screening performed by Medicare contractors or by the Medicaid or Children’s Health Insurance Program agency of another state.⁠¹ A practice already enrolled in Medicare can ask the state whether that screening carries over. A separate Children’s Health Insurance Program screens providers under the same part 455, subpart E rules.⁠¹⁵

Treat enrollment as a series of separate milestones, each with its own record: the state’s screening and enrollment, the signed provider agreement, a contract with each managed care plan, the authorization for a patient’s care where the program requires one, and payment of the claim. Approval at one step does not complete the next, and a practice that keeps them apart can always tell a family exactly where it stands.

This guide covers the Medicaid-specific steps for OT, PT and SLP practices. The credentialing guide covers the provider file, Medicare, commercial plans, status labels and the months while applications are pending, and is the place to start if Medicaid is one payer among several.

Do PT, OT and speech therapy need an order to be paid by Medicaid?

Yes, and the federal wording differs by discipline. Physical therapy and occupational therapy are services “prescribed by a physician or other licensed practitioner of the healing arts” within the scope of state law, while speech, hearing and language services are those for which the patient “is referred by” such a practitioner.⁠³ Whatever your state’s practice act says about evaluating without a referral, the Medicaid benefit is written around a prescription for PT and OT and a referral for speech services, so check the state’s Medicaid manual for what the order must contain, who may sign it and how long it lasts.

The qualifications differ too. PT and OT services are provided by or under the direction of a qualified physical or occupational therapist who meets the personnel qualifications in 42 CFR 484.115.⁠³ Speech services are provided by or under the direction of a speech pathologist or audiologist, and a speech pathologist is someone who holds ASHA’s certificate of clinical competence, has completed the equivalent education and work experience, or has completed the academic program and is acquiring the supervised experience to qualify.⁠³ Ask the state whether therapy assistants can furnish Medicaid services, and under what supervision, before scheduling one with a Medicaid patient.

Must the doctor who orders therapy also be enrolled in Medicaid?

Yes. The state must require every ordering or referring physician or other professional to be enrolled as a participating provider, and every claim for an ordered or referred service must carry the NPI of the professional who ordered or referred it.⁠^1,4 A pediatric practice depends on pediatricians, developmental pediatricians and specialists for its orders; an adult practice on primary care, physiatry, neurology, orthopedics and hospital teams. Check each regular source of orders before the first Medicaid visit, ask the enrollment line how the state lets you confirm an ordering practitioner’s enrollment, and record the answer in the patient’s account. The pediatrician referral guide and the adult referral guide cover building those relationships.

Does Medicaid cover therapy the same way for children and adults?

No. For children and young adults under 21, the EPSDT benefit requires states to provide any additional service that federal Medicaid can cover and that is medically necessary to treat, correct or reduce a condition, whether or not the state’s plan covers it; for adults, physical therapy, occupational therapy and speech, hearing and language services are optional benefits a state chooses to add.⁠^5,6

For children, Medicaid.gov describes EPSDT as comprehensive and preventive care for children under age 21 who are enrolled in Medicaid, and states determine medical necessity case by case.⁠⁵ That makes the documentation of each child’s need, and the state’s process for deciding it, central to a pediatric practice’s Medicaid work; the EPSDT guide covers what that documentation shows, prior authorization, appeals and the move to adult benefits at 21.

For adults, states provide optional benefits only if they add them through the state plan process.⁠⁶ Adults in the Medicaid expansion group are covered through an Alternative Benefit Plan, which is mandatory for that population and must include essential health benefits in ten categories, one of them rehabilitative and habilitative services and devices; habilitative coverage follows the services in the state’s base benchmark plan.⁠^6,16 Every service a state covers must be sufficient in amount, duration and scope to reasonably achieve its purpose, and the agency may place appropriate limits based on medical necessity or utilization control procedures.⁠¹⁷ So visit limits, covered services and authorization rules for adults come from your state’s plan, not from a federal list.

The enrollment belongs to the practice, but the benefit behind each patient depends on age and eligibility group. A practice that serves both should look up the pediatric and adult rules separately, and plan for the day a patient turns 21 and EPSDT no longer applies; the pediatric-to-adult transition guide covers that handoff.⁠⁵ The family guide to finding therapy with Medicaid, disability or language needs explains the same split to parents and adult patients.

What changes when an adult patient has both Medicare and Medicaid?

Medicare pays first when your practice is enrolled in Medicare. CMS states that a Medicare-enrolled provider treating a full-benefit dually eligible patient for a service both programs cover should bill Original Medicare as the primary payer, since Medicaid is generally the payer of last resort.⁠¹⁸ If the practice is enrolled only in Medicaid, the state pays primary for a Medicaid-covered service to a full-benefit dually eligible patient in Original Medicare, and CMS notes that no federal law requires Medicaid providers to enroll in Medicare.⁠¹⁸

Patients in the Qualified Medicare Beneficiary group must not be billed for Medicare Part A or Part B cost sharing by any Medicare provider, including providers who do not accept Medicaid, and that holds even when Medicaid pays nothing toward it.⁠¹⁹ The state must let Medicare-enrolled providers that meet the federal Medicaid enrollment requirements enroll in Medicaid to process claims for that cost sharing, even when the provider type is not recognized in the state plan.⁠^1,19 For an adult practice that sees older or disabled patients, that crossover enrollment can be reason enough to enroll.

What do you need ready before applying to your state Medicaid program?

Identifiers, licenses, ownership facts and clean exclusion checks, because the state verifies each one. Start with the NPI: a covered health care provider must obtain one and report changes to its required data within 30 days, and the Medicaid provider agreement requires the provider to give the state its NPI and include it on every claim.⁠^20,21 CMS’s NPI fact sheet distinguishes Type 1 NPIs for individual providers, one per person, from Type 2 NPIs for organizations, notes that an incorporated provider can hold one of each, and states that having an NPI does not enroll a provider in a health plan.⁠²²

Licenses come next. The state must verify that a provider claiming a license holds it, that it has not expired and that it carries no current limitations, and its screening includes licenses held in states other than the one where you are enrolling.⁠^7,23

Run your own exclusion checks before the state runs its. The state checks providers and their owners, agents and managing employees against the Social Security Administration’s Death Master File, NPPES, the List of Excluded Individuals/Entities (LEIE) and the Excluded Parties List System, and rechecks the LEIE and EPLS at least monthly.⁠²⁴ OIG states that excluded individuals and entities can receive no payment from federal health care programs for items or services they furnish, order or prescribe, and that anyone who hires a person or entity on the LEIE may be subject to civil monetary penalties.⁠²⁵

Ownership questions reach further than the license holder. Any person with a 5 percent or greater ownership interest can be asked for fingerprints within 30 days, and the state must terminate an enrollment when such an owner does not submit timely and accurate information and cooperate with screening.⁠^26,27 Before the agency enters into or renews a provider agreement, the provider must disclose any owner, agent or managing employee who has been convicted of a crime related to Medicare, Medicaid or the title XX services program.⁠²⁸

How does Medicaid screen a therapy practice, and what risk level applies?

The state assigns each provider category a risk level of limited, moderate or high and screens to it. At the limited level the state verifies that the provider meets federal and state requirements for its type, checks licenses and runs database checks before and after enrollment; moderate adds on-site visits; high adds a criminal background check and fingerprints.⁠⁷ The state sets the categories and their levels itself, and when a provider could fit more than one level, the highest applies.⁠⁷ The same screening runs on initial applications, applications for a new practice location, re-enrollment and revalidation.⁠⁷

A state may rely on screening Medicare has already done.⁠¹ Medicare’s screening splits the three disciplines: CMS designates occupational therapists, speech-language pathologists and medical groups or clinics as limited risk, and physical therapists enrolling as individuals or as group practices as moderate risk.⁠⁸ Do not assume your state uses the same split; ask which category and risk level your enrollment type carries.

For moderate and high-risk providers, the state must make site visits before and after enrollment, to verify that the application is accurate and that the provider meets federal and state enrollment requirements.⁠²⁹ Every enrolled provider must also permit unannounced on-site inspections of any of its locations, and the state must terminate or deny enrollment when a provider refuses access for a site visit, unless it documents that doing so is not in the program’s best interest.⁠^27,29 Keep the address on the application the place where care actually happens, with the practice’s name visible and staff who know a visit can come.

When the state screens at the high level, the provider and anyone with a 5 percent or greater ownership interest submit fingerprints, and a person required to do so who does not may see the application denied or the enrollment terminated.⁠^7,26 A state may also impose a temporary moratorium on enrolling new providers of a type the Secretary of Health and Human Services has identified as high risk; once imposed, it must run for an initial period of 6 months, so ask whether any moratorium covers your provider type before you apply.⁠³⁰

Is there an application fee to enroll as a Medicaid provider?

Usually not for an individual practitioner. States must collect the application fee before executing a provider agreement, but not from individual physicians or nonphysician practitioners, and not from a provider that has already paid it to a Medicare contractor or another state.⁠³¹ For 2026 the fee is $750 for institutional providers; CMS describes Medicaid-only institutional providers as nursing facilities, intermediate care facilities for people with intellectual disabilities and psychiatric residential treatment facilities, and adds that they may include other institutional provider types a state designates in its approved state plan.⁠³² Whether a therapy group or agency counts as institutional is the state’s classification, so ask before paying, and keep the receipt: a later reactivation can bring the fee back.⁠¹³

Should your practice take fee-for-service Medicaid, managed care or both?

Decide by where the Medicaid patients you would see get their coverage, because state enrollment alone does not put you in a managed care plan’s network. Medicaid managed care delivers benefits through contracts between the state agency and managed care organizations that are paid a set amount per member per month.⁠³³ Every network provider of those plans must still be screened and enrolled by the state, though that enrollment does not require the provider to see fee-for-service patients.⁠²

Before choosing, ask the state agency which plans serve children and adults in your area, read the published fee schedule for the codes each discipline bills, and ask each plan whether its network for your discipline is open. A practice that sees only adults and a practice that sees only children can reach different answers in the same county, because the benefits differ.⁠⁶ Where a plan’s offered rate is the deciding factor, the guide to negotiating reimbursement rates covers preparing for that conversation.

How do you join a Medicaid managed care plan’s network?

Apply to each plan separately, alongside or after state enrollment, and keep each contract’s status apart. Each state must set a uniform credentialing and recredentialing policy that every plan follows, each plan must follow a documented credentialing process, and plans must meet any additional requirements the state sets.⁠⁹ A plan may sign a network agreement while your state screening is pending for up to 120 days, but must end it immediately if the state says you cannot be enrolled or the 120 days pass without enrollment, and must notify the enrollees affected.⁠²

A plan does not have to take every applicant. It may not discriminate against a provider acting within the scope of a license solely on the basis of that license, and when it declines to include a provider it must give written notice of the reason; but it need not contract with more providers than its enrollees need, and it may pay different amounts for different specialties or for different practitioners in the same specialty.⁠³⁴ Ask for the reason in writing when a plan says no, and file it with the date.

When a plan’s network cannot provide a necessary covered service to a particular enrollee, the plan must cover it out of network, adequately and timely, for as long as the network cannot provide it, and the out-of-network provider coordinates with the plan for payment.⁠³⁵ That arrangement is for one enrollee; get its terms, the authorization and the rate in writing before the first visit.

What does a Medicaid plan’s provider directory have to show?

Each plan’s directory must show a network provider’s name and group affiliation, street address, phone number, website, specialty, whether the provider accepts new enrollees, languages offered by the provider or a skilled medical interpreter, including American Sign Language, physical accessibility of the office and equipment, and whether covered services are offered by telehealth.⁠³⁶ The federal list of provider types the directory must cover names physicians, hospitals, pharmacies, mental health and substance use disorder providers and LTSS providers; therapists are not named, so ask each plan whether and how it lists your clinic.⁠³⁶ An electronic directory must be updated no later than 30 calendar days after the plan receives updated information, so send every change in writing and look up the entry once that window has passed.⁠³⁶

How does Medicaid pay therapy claims, and what can patients be billed?

Fee-for-service Medicaid pays the rate on the state’s published fee schedule, a managed care plan pays the rate in its contract, and either way the practice accepts that payment plus any cost sharing the plan requires as payment in full.⁠^10,11,34

Each state must publish all of its fee-for-service fee schedule rates on a public website reachable from the agency’s own site, organized so a member of the public can readily determine what Medicaid pays for a given service, and separated by population, pediatric and adult, by provider type and by location where rates vary; the first publication was due no later than July 1, 2026.⁠¹¹ Look up the codes you bill for each discipline and age group before you decide which path to take.

Participation is limited to providers who accept, as payment in full, the amounts the agency pays plus any deductible, coinsurance or copayment the plan requires the patient to pay.⁠¹⁰ Do not bill a Medicaid patient the difference between your usual fee and the Medicaid rate, and train the front desk to say so before the first visit. The insurance and fees guide covers explaining participation, benefits and authorization plainly, and what a public insurance statement should say.

Claims have federal clocks. The state must require claims within 12 months of the date of service, and must pay 90 percent of practitioners’ clean claims within 30 days of receipt and 99 percent within 90 days; a managed care contract must meet the same two payment standards unless the plan and its providers agree an alternative schedule written into the contract.⁠^37,38 A plan’s own filing deadline is in its contract, so read it there.

How quickly must Medicaid decide a therapy prior authorization?

Within 7 calendar days for a standard request and 72 hours for an expedited one, under the federal limits that apply in 2026, and a state can set shorter ones.⁠^17,39 For fee-for-service the 7-day limit began on January 1, 2026, and can be extended by up to 14 calendar days when the beneficiary or provider asks or the agency needs more information from the provider.⁠¹⁷ Managed care plans apply the same 7-day limit for rating periods that start on or after January 1, 2026, with up to 14 more days in the cases the rule allows.⁠³⁹

Each state must post its previous year’s prior authorization data by March 31 each year, starting with a list of all items and services that require prior authorization, so check whether your codes are on it before the first evaluation.⁠¹⁷ Record each authorization’s number, dates and visit count on the patient’s account, and match every claim to it.

What does a Medicaid provider agreement commit your practice to?

To keeping records and sharing them. The federal minimum, which covers individual practitioners and groups alike, is an agreement to keep the records needed to show the extent of the services you furnish, to give those records and information about payments claimed to the agency, the Secretary or the state Medicaid fraud control unit on request, to meet the disclosure rules, and to give the state your NPI and include it on all claims.⁠²¹ Every enrolled provider must also permit unannounced on-site inspections of any of its locations.⁠²⁹

Read the state’s agreement, and the provider manual it points to, before signing. Look there first for the state’s documentation, order and authorization rules for each discipline, and keep a signed, dated copy of the agreement in the enrollment file.

The agreement can end. The state must terminate or deny enrollment when the provider, or an owner, agent or managing employee, fails to submit timely or accurate information, unless it documents that doing so is not in the program’s best interest, and it may terminate or deny enrollment when an application is falsified.⁠²⁷ A provider terminated or denied on those grounds has whatever appeal rights the state’s law or regulations provide.⁠⁴⁰

How do you track a Medicaid application from submission to decision?

Keep one block per program or plan, with the date, the person you spoke to and the confirmation or reference number for every step, so each status has a source. Do not record a step as complete on the strength of a phone call; record what was said, and by whom, until the letter or portal notice arrives. The status labels in the credentialing guide work for Medicaid as well.

What should you ask when you call the state’s enrollment line?

Ask the questions whose answers change what you submit, and end every call with a name and a reference number. The script below fits a first call before applying or a follow-up on a pending application.

What does Medicaid enrollment look like for a clinic serving all ages?

It looks like several tracks moving at once, each with its own status. The example below is hypothetical; its sequence follows the federal rules cited in this guide, and its timings are inputs, not typical figures.

How do you keep Medicaid enrollment active after approval?

Revalidate when the state asks, at least every five years, report changes promptly and keep your staff checks current. The state must revalidate every provider’s enrollment at least every 5 years, and revalidation applications are screened like initial ones.⁠^7,12 After a deactivation for any reason, the enrollment cannot be reactivated until the state re-screens the provider and collects any application fee that applies.⁠¹³ Find what triggers a deactivation in your state’s provider manual, and put it in the calendar beside the revalidation date.

Report changes in the places that hold them. A covered provider must report changes to its NPPES data within 30 days, and a new practice location goes through screening as its own application.⁠^7,20 Ask the state how it wants other changes reported, such as a new owner, a new clinician or a closed location, and keep the confirmation.

Check new hires against the LEIE before they start and recheck current staff on a schedule. The state checks it monthly, plans may not employ or contract with excluded providers, and OIG advises health care entities to check the list routinely for new hires and current employees.⁠^9,24,25

Each plan recredentials its network under the state’s uniform policy, so put every plan’s recredentialing date in the same calendar.⁠⁹

• Every month: LEIE checks for new hires and current staff; directory entries checked against what you sent each plan⁠²⁴
• Every quarter: fee schedule and prior authorization list reviewed for the codes you bill
• Every year: each plan’s contract terms, filing deadline and recredentialing date reviewed
• At least every five years: state revalidation, with the enrollment checklist above brought up to date⁠¹²

How should you tell families which Medicaid plans you accept?

Name the program and every plan, for each discipline and age group, and use the same words on your website, phone script and listings. “We take Medicaid” can mislead a family whose child is in a plan you have not joined, or an adult whose eligibility group covers fewer services. Keep each plan’s directory entry accurate too, including whether you accept new enrollees, since the directory is the information each plan gives its members about its network.⁠³⁶

DrSensory is a free directory where families look for OT, PT and speech therapy clinics serving children and adults in all 50 states and Washington, DC; it lists clinics rather than individual therapists, one listing per practice at one address.⁠^41,42 A basic listing costs nothing, and so does claiming it: you find the listing, confirm your email address with a six-digit code and set a password.⁠⁴¹ The paid listing, $29.99 a month or $349.99 a year for the first location and $9.99 a month or $99.99 a year for each additional location, with no contract, adds a description in your own words, where a clinic can state which Medicaid programs and plans it accepts; family inquiries are read in the clinic’s portal and answered from its own address.⁠^41,42 DrSensory does not verify clinical quality, so a listing says where a clinic is and what it offers, not that it is recommended.⁠⁴² The profile guide covers writing that About text, and the intake call script covers answering a family who asks whether therapy is covered.

Sources

1. 42 CFR. §455.410, Enrollment and screening of providers (Medicaid provider screening and enrollment, part 455, subpart E). Checked October 24, 2026.
   Show the passageHide the passage

   “The State Medicaid agency must require all enrolled providers to be screened under to this subpart.”; “The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.”; “The State Medicaid agency may rely on the results of the provider screening performed by any of the following: (1) Medicare contractors. (2) Medicaid agencies or Children’s Health Insurance Programs of other States.”; “The State Medicaid agency must allow enrollment of all Medicare-enrolled providers and suppliers for purposes of processing claims to determine Medicare cost-sharing (as defined in section 1905(p)(3) of the Act) if the providers or suppliers meet all Federal Medicaid enrollment requirements”; “This paragraph (d) applies even if the Medicare-enrolled provider or supplier is of a type not recognized by the State Medicaid Agency.”.
2. 42 CFR. §438.602, State responsibilities (Medicaid managed care, paragraph (b), screening, enrollment and revalidation of providers). Checked October 24, 2026.
   Show the passageHide the passage

   “The State must screen and enroll, and periodically revalidate, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E of this chapter.”; “This provision does not require the network provider to render services to FFS beneficiaries.”; “MCOs, PIHPs, and PAHPs may execute network provider agreements pending the outcome of the process in paragraph (b)(1) of this section of up to 120 days, but must terminate a network provider immediately upon notification from the State that the network provider cannot be enrolled, or the expiration of one 120 day period without enrollment of the provider, and notify affected enrollees.”.
3. 42 CFR. §440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Medicaid services, definitions). Checked October 24, 2026.
   Show the passageHide the passage

   “Physical therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified physical therapist.”; “Occupational therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified occupational therapist.”; “Services for individuals with speech, hearing, and language disorders means diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech pathologist or audiologist, for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law.”; “A “qualified physical therapist” is an individual who meets personnel qualifications for a physical therapist at § 484.115.”; “A “qualified occupational therapist” is an individual who meets personnel qualifications for an occupational therapist at § 484.115.”; “A “speech pathologist” is an individual who meets one of the following conditions: (i) Has a certificate of clinical competence from the American Speech and Hearing Association. (ii) Has completed the equivalent educational requirements and work experience necessary for the certificate. (iii) Has completed the academic program and is acquiring supervised work experience to qualify for the certificate.”.
4. 42 CFR. §455.440, National Provider Identifier (part 455, subpart E). “The State Medicaid agency must require all claims for payment for items and services that were ordered or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered or referred such items or services.”. Checked October 24, 2026.
5. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (the EPSDT benefit). Checked October 24, 2026.
   Show the passageHide the passage

   “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
6. Medicaid.gov. Mandatory & Optional Medicaid Benefits (the federal list of state plan benefits). Checked October 24, 2026.
   Show the passageHide the passage

   “States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process.”; “Physical therapy (1905(a)(11), 42 CFR 440.110(a))”; “Occupational therapy (1905(a)(11), 42 CFR 440.110(b))”; “Speech, hearing and language disorder services (1905(a)(11), 42 CFR 440.110(c))”; “The ABP is mandatory for the Medicaid expansion population.”.
7. 42 CFR. §455.450, Screening levels for Medicaid providers (part 455, subpart E). Checked October 24, 2026.
   Show the passageHide the passage

   “A State Medicaid agency must screen all initial applications, including applications for a new practice location, and any applications received in response to a re-enrollment or revalidation of enrollment request based on a categorical risk level of “limited,” “moderate,” or “high.””; “If a provider could fit within more than one risk level described in this section, the highest level of screening is applicable.”; “Verify that a provider meets any applicable Federal regulations, or State requirements for the provider type prior to making an enrollment determination.”; “Conduct license verifications, including State licensure verifications in States other than where the provider is enrolling”; “Conduct database checks on a pre- and post-enrollment basis”; “Conduct on-site visits in accordance with § 455.432.”; “(2)(i) Conduct a criminal background check; and (ii) Require the submission of a set of fingerprints in accordance with § 455.434.”; “who is required by the State Medicaid agency or CMS to submit a set of fingerprints and fails to do so may have its— (1) Application denied under § 455.434; or (2) Enrollment terminated under § 455.416.”.
8. 42 CFR. §424.518, Screening levels for Medicare providers and suppliers (Medicare; paragraphs (a) and (b)). “Physician or nonphysician practitioners (including nurse practitioners, CRNAs, occupational therapists, speech/language pathologists, and audiologists) and medical groups or clinics.”; “Physical therapists enrolling as individuals or as group practices.”. Checked October 24, 2026.
9. 42 CFR. §438.214, Provider selection (Medicaid managed care). Checked October 24, 2026.
   Show the passageHide the passage

   “Each State must establish a uniform credentialing and recredentialing policy that addresses acute, primary, mental health, substance use disorders, and LTSS providers, as appropriate, and requires each MCO, PIHP and PAHP to follow those policies.”; “Each MCO, PIHP, and PAHP must follow a documented process for credentialing and recredentialing of network providers.”; “MCOs, PIHPs, and PAHPs may not employ or contract with providers excluded from participation in Federal health care programs”; “Each MCO, PIHP, and PAHP must comply with any additional requirements established by the State.”.
10. 42 CFR. §447.15, Acceptance of State payment as payment in full (Medicaid payments). Checked October 24, 2026.
    Show the passageHide the passage

    “A State plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual.”.
11. 42 CFR. §447.203, Documentation of access to care and service payment rates (Medicaid payments, paragraph (b)(1), payment rate transparency). Checked October 24, 2026.
    Show the passageHide the passage

    “The State agency is required to publish all Medicaid fee-for-service fee schedule payment rates on a website that is accessible to the general public.”; “The website where the State agency publishes its Medicaid fee-for-service payment rates must be easily reached from a hyperlink on the State Medicaid agency’s website.”; “Medicaid fee-for-service payment rates must be organized in such a way that a member of the public can readily determine the amount that Medicaid would pay for a given service.”; “If the rates vary, the State must separately identify the Medicaid fee-for-service payment rates by population (pediatric and adult), provider type, and geographical location, as applicable.”; “The initial publication of the Medicaid fee-for-service payment rates shall occur no later than July 1, 2026”.
12. 42 CFR. §455.414, Revalidation of enrollment (part 455, subpart E). “The State Medicaid agency must revalidate the enrollment of all providers regardless of provider type at least every 5 years.”. Checked October 24, 2026.
13. 42 CFR. §455.420, Reactivation of provider enrollment (part 455, subpart E). “After deactivation of a provider enrollment number for any reason, before the provider’s enrollment may be reactivated, the State Medicaid agency must re-screen the provider and require payment of associated provider application fees under § 455.460.”. Checked October 24, 2026.
14. 42 CFR. §455.452, Other State screening methods (part 455, subpart E). “Nothing in this subpart must restrict the State Medicaid agency from establishing provider screening methods in addition to or more stringent than those required by this subpart.”. Checked October 24, 2026.
15. 42 CFR. §457.990, Provider and supplier screening, oversight, and reporting requirements (the Children’s Health Insurance Program). Checked October 24, 2026.
    Show the passageHide the passage

    “The following provisions and their corresponding regulations apply to a State under title XXI of the Act, in the same manner as these provisions and regulations apply to a State under title XIX of the Act:”; “Part 455, subpart E, of this chapter.”.
16. 42 CFR. §440.347, Essential health benefits (Medicaid Alternative Benefit Plans). Checked October 24, 2026.
    Show the passageHide the passage

    “Alternative Benefit Plans must contain essential health benefits coverage, including benefits in each of the following ten categories”; “Rehabilitative and habilitative services and devices”; “Alternative Benefit Plan coverage of habilitative services and devices will be based on the habilitative services and devices that are in the applicable base benchmark plan.”.
17. 42 CFR. §440.230, Sufficiency of amount, duration, and scope (Medicaid services; paragraph (e), prior authorization). Checked October 24, 2026.
    Show the passageHide the passage

    “Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.”; “The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures.”; “Beginning January 1, 2026, make prior authorization decisions within the following timeframes:”; “For a standard determination, as expeditiously as a beneficiary’s health condition requires, but in no case later than 7 calendar days after receiving the request, unless a shorter minimum timeframe is established under State law.”; “The timeframe for standard authorization decisions can be extended by up to 14 calendar days if the beneficiary or provider requests an extension, or if the State agency determines that additional information from the provider is needed to make a decision.”; “For an expedited determination, as expeditiously as a beneficiary’s health condition requires, but in no case later than 72 hours after receiving the request, unless a shorter minimum timeframe is established under State law.”; “Beginning in 2026, annually report prior authorization data, excluding data on drugs, as defined in § 431.60(b)(6) of this chapter, at the State level by March 31. The State must make the following data from the previous calendar year publicly accessible by posting them on its website: (i) A list of all items and services that require prior authorization.”.
18. Centers for Medicare & Medicaid Services. Provider Enrollment and Third Party Liability for Items and Services Rendered to Dually Eligible Individuals (frequently asked questions, version date January 14, 2025). Checked October 24, 2026.
    Show the passageHide the passage

    “The state would pay primary for a Medicaid-covered item or service provided by a Medicaid-enrolled provider or supplier for a full-benefit dually eligible individual when the provider or supplier is not also enrolled in Medicare”; “We note that there is no federal law or requirement for Medicaid providers or suppliers to enroll in Medicare.”; “If the provider or supplier is enrolled in Medicare and provides an item or service covered by Medicare and Medicaid to a full-benefit dually eligible individual, then the provider or supplier should bill Original Medicare as the primary payer as Medicaid is generally the payer of last resort for items and services provided to full-benefit dually eligible individuals.”.
19. Centers for Medicare & Medicaid Services, Medicare Learning Network. Prohibition on Billing Qualified Medicare Beneficiaries (MLN7936176, fact sheet, September 2025). Checked October 24, 2026.
    Show the passageHide the passage

    “Medicare providers and suppliers, including pharmacies, must not bill Medicare patients in the Qualified Medicare Beneficiary (QMB) group for Medicare Part A or Medicare Part B cost sharing.”; “Federal law prohibits all Original Medicare and MA providers and suppliers (not only those that accept Medicaid) from billing QMBs for Part A and Part B cost sharing.”; “Even if you don’t receive full payment from Medicaid, you must not bill a QMB.”; “may be subject to sanctions if you don’t follow QMB billing prohibitions (even when Medicaid pays nothing)”; “States must have a way for Medicare providers to enroll in the Medicaid program for processing QMB claims for state payment of Medicare cost sharing even if a service or provider category isn’t currently recognized in the Medicaid State Plan.”.
20. 45 CFR. §162.410, Implementation specifications: Health care providers (HIPAA administrative requirements, the National Provider Identifier). Checked October 24, 2026.
    Show the passageHide the passage

    “A covered entity that is a covered health care provider must: (1) Obtain, by application if necessary, an NPI from the National Provider System (NPS) for itself”; “Communicate to the NPS any changes in its required data elements in the NPS within 30 days of the change.”; “A health care provider that is not a covered entity may obtain, by application if necessary, an NPI from the NPS.”.
21. 42 CFR. §431.107, Required provider agreement (Medicaid state organization and general administration). Checked October 24, 2026.
    Show the passageHide the passage

    “relate to the keeping of records and the furnishing of information by all providers of services (including individual practitioners and groups of practitioners)”; “A State plan must provide for an agreement between the Medicaid agency and each provider or organization furnishing services under the plan in which the provider or organization agrees to: (1) Keep any records necessary to disclose the extent of services the provider furnishes to beneficiaries;”; “On request, furnish to the Medicaid agency, the Secretary, or the State Medicaid fraud control unit”; “Furnish to the State agency its National Provider Identifier (NPI) (if eligible for an NPI); and (ii) Include its NPI on all claims submitted under the Medicaid program.”.
22. Centers for Medicare & Medicaid Services. NPI Fact Sheet (December 2024). Checked October 24, 2026.
    Show the passageHide the passage

    “Health plans including Medicare, Medicaid and private health plans require National Provider Identifiers (NPIs) in their administrative and financial transactions.”; “Type 1: For individual health care providers, such as physicians, nurse practitioners and sole proprietors. Individuals are only eligible for one NPI.”; “Type 2: For health care organizations, such as hospitals, nursing homes, and physician groups. Organizations can have multiple NPIs.”; “An individual who is a health care provider and is incorporated, can obtain an NPI for themselves (Type 1) and an NPI for their corporation or LLC (Type 2).”; “Having an NPI does not:”; “Enroll a provider in a health plan”.
23. 42 CFR. §455.412, Verification of provider licenses (part 455, subpart E). “Have a method for verifying that any provider purporting to be licensed in accordance with the laws of any State is licensed by such State.”; “Confirm that the provider’s license has not expired and that there are no current limitations on the provider’s license.”. Checked October 24, 2026.
24. 42 CFR. §455.436, Federal database checks (part 455, subpart E). “Check the Social Security Administration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the Excluded Parties List System (EPLS), and any such other databases as the Secretary may prescribe.”; “Check the LEIE and EPLS no less frequently than monthly.”. Checked October 24, 2026.
25. U.S. Department of Health and Human Services, Office of Inspector General. Exclusions Program (the List of Excluded Individuals/Entities). Checked October 24, 2026.
    Show the passageHide the passage

    “Those that are excluded can receive no payment from Federal health care programs for any items or services they furnish, order, or prescribe.”; “Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, health care entities should routinely check the list to ensure that new hires and current employees are not on it.”.
26. 42 CFR. §455.434, Criminal background checks (part 455, subpart E). Checked October 24, 2026.
    Show the passageHide the passage

    “As a condition of enrollment, must require providers to consent to criminal background checks including fingerprinting when required to do so under State law or by the level of screening based on risk of fraud, waste or abuse as determined for that category of provider.”; “Must establish categorical risk levels for providers and provider categories who pose an increased financial risk of fraud, waste or abuse to the Medicaid program.”; “Upon the State Medicaid agency determining that a provider, or a person with a 5 percent or more direct or indirect ownership interest in the provider, meets the State Medicaid agency’s criteria hereunder for criminal background checks as a “high” risk to the Medicaid program, the State Medicaid agency will require that each such provider or person submit fingerprints.”; “The State Medicaid agency must require a provider, or any person with a 5 percent or more direct or indirect ownership interest in the provider, to submit a set of fingerprints, in a form and manner to be determined by the State Medicaid agency, within 30 days upon request from CMS or the State Medicaid agency.”.
27. 42 CFR. §455.416, Termination or denial of enrollment (part 455, subpart E). Checked October 24, 2026.
    Show the passageHide the passage

    “Must terminate the enrollment of any provider where any person with a 5 percent or greater direct or indirect ownership interest in the provider did not submit timely and accurate information and cooperate with any screening methods required under this subpart.”; “Must terminate the provider’s enrollment or deny enrollment of the provider if the provider or a person with an ownership or control interest or who is an agent or managing employee of the provider fails to submit timely or accurate information, unless the State Medicaid agency determines that termination or denial of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing.”; “Must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visits under § 455.432, unless the State Medicaid agency determines that termination or denial of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing.”; “May terminate or deny the provider’s enrollment if CMS or the State Medicaid agency— (1) Determines that the provider has falsified any information provided on the application”.
28. 42 CFR. §455.106, Disclosure by providers: Information on persons convicted of crimes (part 455, subpart B). Checked October 24, 2026.
    Show the passageHide the passage

    “Before the Medicaid agency enters into or renews a provider agreement, or at any time upon written request by the Medicaid agency, the provider must disclose to the Medicaid agency the identity of any person who: (1) Has ownership or control interest in the provider, or is an agent or managing employee of the provider; and (2) Has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or the title XX services program since the inception of those programs.”.
29. 42 CFR. §455.432, Site visits (part 455, subpart E). Checked October 24, 2026.
    Show the passageHide the passage

    “Must conduct pre-enrollment and post-enrollment site visits of providers who are designated as “moderate” or “high” categorical risks to the Medicaid program.”; “to verify that the information submitted to the State Medicaid agency is accurate and to determine compliance with Federal and State enrollment requirements”; “Must require any enrolled provider to permit CMS, its agents, its designated contractors, or the State Medicaid agency to conduct unannounced on-site inspections of any and all provider locations.”.
30. 42 CFR. §455.470, Temporary moratoria (part 455, subpart E). Checked October 24, 2026.
    Show the passageHide the passage

    “A State Medicaid agency may impose temporary moratoria on enrollment of new providers, or impose numerical caps or other limits that the State Medicaid agency identifies as having a significant potential for fraud, waste, or abuse and that the Secretary has identified as being at high risk for fraud, waste, or abuse.”; “The State Medicaid agency must impose the moratorium for an initial period of 6 months.”.
31. 42 CFR. §455.460, Application fee (part 455, subpart E). Checked October 24, 2026.
    Show the passageHide the passage

    “States must collect the applicable application fee prior to executing a provider agreement from a prospective or re-enrolling provider other than either of the following: (1) Individual physicians or nonphysician practitioners.”; “Providers that have paid the applicable application fee to— (A) A Medicare contractor; or (B) Another State.”.
32. Centers for Medicare & Medicaid Services, Federal Register. Medicare, Medicaid, and Children’s Health Insurance Programs; Provider Enrollment Application Fee Amount for Calendar Year 2026 (notice, 90 FR 55738, December 3, 2025). Checked October 24, 2026.
    Show the passageHide the passage

    “This notice announces a $750.00 calendar year (CY) 2026 application fee for institutional providers that are initially enrolling in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP); revalidating their Medicare, Medicaid, or CHIP enrollment; or adding a new Medicare practice location.”; “Medicaid-only and CHIP-only institutional providers would include nursing facilities, intermediate care facilities for persons with intellectual disabilities (ICF/IID), and psychiatric residential treatment facilities; they may also include other institutional provider types designated by a state in accordance with their approved state plan.”; “the application fee is not required for either of the following”; “A prospective or revalidating Medicaid or CHIP provider”; “Who is an individual physician or non-physician practitioner”.
33. Medicaid.gov. Managed Care (overview page). “Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services.”. Checked October 24, 2026.
34. 42 CFR. §438.12, Provider discrimination prohibited (Medicaid managed care). Checked October 24, 2026.
    Show the passageHide the passage

    “An MCO, PIHP, or PAHP may not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification.”; “If an MCO, PIHP, or PAHP declines to include individual or groups of providers in its provider network, it must give the affected providers written notice of the reason for its decision.”; “Require the MCO, PIHP, or PAHP to contract with providers beyond the number necessary to meet the needs of its enrollees;”; “Preclude the MCO, PIHP, or PAHP from using different reimbursement amounts for different specialties or for different practitioners in the same specialty;”.
35. 42 CFR. §438.206, Availability of services (Medicaid managed care). Checked October 24, 2026.
    Show the passageHide the passage

    “If the provider network is unable to provide necessary services, covered under the contract, to a particular enrollee, the MCO, PIHP, or PAHP must adequately and timely cover these services out of network for the enrollee, for as long as the MCO, PIHP, or PAHP’s provider network is unable to provide them.”; “Requires out-of-network providers to coordinate with the MCO, PIHP, or PAHP for payment and ensures the cost to the enrollee is no greater than it would be if the services were furnished within the network.”.
36. 42 CFR. §438.10, Information requirements (Medicaid managed care, paragraph (h), the provider directory). Checked October 24, 2026.
    Show the passageHide the passage

    “Each MCO, PIHP, PAHP, and when appropriate, the PCCM entity, must make available in paper form upon request and searchable electronic form, the following information about its network providers: (i) The provider’s name as well as any group affiliation. (ii) Street address(es). (iii) Telephone number(s). (iv) Web site URL, as appropriate. (v) Specialty, as appropriate. (vi) Whether the provider will accept new enrollees.”; “The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office.”; “Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment.”; “Whether the provider offers covered services via telehealth.”; “The provider directory must include the information in paragraph (h)(1) of this section for each of the following provider types covered under the contract: (i) Physicians, including specialists; (ii) Hospitals; (iii) Pharmacies; (iv) Mental health and substance use disorder providers; and (v) LTSS providers, as appropriate.”; “An electronic provider directory must be updated no later than 30 calendar days after the MCO, PIHP, PAHP, or PCCM entity receives updated provider information.”.
37. 42 CFR. §447.45, Timely claims payment (Medicaid payments, paragraph (d)). Checked October 24, 2026.
    Show the passageHide the passage

    “The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service.”; “The agency must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt.”; “The agency must pay 99 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 90 days of the date of receipt.”.
38. 42 CFR. §447.46, Timely claims payment by MCOs (Medicaid payments). “A contract with an MCO must provide that the organization will meet the requirements of § 447.45(d)(2) and (d)(3)”; “The MCO and its providers may, by mutual agreement, establish an alternative payment schedule.”; “Any alternative schedule must be stipulated in the contract.”. Checked October 24, 2026.
39. 42 CFR. §438.210, Coverage and authorization of services (Medicaid managed care, paragraph (d), timeframes for decisions). Checked October 24, 2026.
    Show the passageHide the passage

    “For rating periods that start on or after January 1, 2026, within state established time frames that may not exceed 7 calendar days after receiving the request for service.”; “Standard authorization decisions may have an extension to the timeframes in paragraph (d)(1)(i) of this section up to 14 additional calendar days”; “the MCO, PIHP, or PAHP must make an expedited authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than 72 hours after receipt of the request for service.”.
40. 42 CFR. §455.422, Appeal rights (part 455, subpart E). “The State Medicaid agency must give providers terminated or denied under § 455.416 any appeal rights available under procedures established by State law or regulations.”. Checked October 24, 2026.
41. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 24, 2026.
    Show the passageHide the passage

    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “across all 50 states and Washington, DC”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “Claiming is free and has three steps: find your listing, confirm your email with a six-digit code, choose a password.”; “There is no contract, and nothing is charged while you claim.”; “Therapy and developmental resources for children and adults, plus a directory of providers across the United States.”.
42. DrSensory. Therapy Clinic Directory Pricing (the pricing page and its frequently asked questions). Checked October 24, 2026.
    Show the passageHide the passage

    “Outpatient physical therapy, occupational therapy, and speech-language pathology clinics. The directory lists clinics rather than individual therapists, so one listing covers your whole practice. Inpatient rehabilitation facilities and chiropractic practices are not listed.”; “$29.99 a month or $349.99 a year for your first location, and $9.99 a month or $99.99 a year for each additional location”; “Claiming your listing is free.”; “A description in your own words”; “We do not verify clinical quality”; “A listing means a practice appears in the directory. It is not a recommendation”; “Families never pay to search it or to contact a clinic”; “When a family writes from your profile, the address you gave for family inquiries is told that a message is waiting; you read it signed in, because what a parent writes about their child is health information, and you reply from your own address.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Each state runs its own Medicaid program under federal rules, so the state’s provider manual and each plan’s contract govern your enrollment, and the example is hypothetical, not DrSensory data.