Physician orders and referrals for therapy

For OT, PT and speech practices seeing children or adults: before scheduling, name which requirement applies (a clinical referral, direct access under state law, a payer’s referral or order, prior authorization, or Medicare plan-of-care certification), then confirm who may issue it, what it must say and which dates it covers. One document rarely settles all five.

What is the difference between a therapy referral and an order?

They answer different questions, and five separate requirements hide behind the two words. HealthCare.gov defines a referral as a primary care doctor’s written order to see a specialist or get certain services, and preauthorization as a plan’s decision that a service is medically necessary; Medicare speaks of certifying a plan of care and has no order requirement for outpatient therapy.⁠^1,13,14

Keep the five apart in the intake record; renaming a document does not make it fit a requirement it was not written for. One document sometimes covers two: under Original Medicare a signed order naming the therapy can double as the certifying signature on a therapist’s initial plan, and under TRICARE Prime the referral and pre-authorization arrive together.⁠^3,10 None of them says whether the plan counts your clinic as in network; the credentialing guide covers that question.

Do patients need a referral to see a PT, OT or speech therapist?

The legal answer depends on the discipline and the state, and the payment answer on the plan, so answer each separately: state law can allow the visit while the plan still wants a referral.⁠⁵

What does direct access mean for physical therapists by state?

It means a patient may see a physical therapist without a physician’s referral, on terms each state sets. By APTA’s count, every state, plus the District of Columbia and the U.S. Virgin Islands, had provisional or unrestricted direct access to PT evaluation and treatment by July 1, 2025, and some states still keep provisions on treatment given without a referral.⁠⁴ APTA’s consumer site adds two caveats for intake: some states limit the duration or type of treatment without a referral, and some plans still require one, sometimes after a set number of visits.⁠⁵

APTA keeps a jurisdiction-by-jurisdiction summary, but the statute is the rule: record the practice act section, any time, visit or treatment limit, and the day you read it.⁠⁴ The screening duty stays with the therapist; APTA’s code tells physical therapists to stay within their professional and jurisdictional scope and refer to other health care professionals when necessary.⁠¹⁶

Do occupational therapists need a physician referral to treat?

The answer sits in each state’s OT practice act, not in a national rule. AOTA notes that occupational therapy practice is regulated by state licensure agencies, and its licensure resources include a state chart of referral requirements, behind a member sign-in.⁠⁶ For each state where the practice treats, record whether evaluation, treatment or both may begin without a referral, and on what terms. Payers add their own rules: TRICARE covers OT only when a TRICARE-authorized physician, certified physician assistant supervised by a physician, certified nurse practitioner or podiatrist prescribes and supervises it.⁠¹¹

Does speech therapy require a prescription or a referral?

Not as a matter of the profession’s scope, but often as a matter of setting or payment. ASHA’s scope of practice describes SLPs as autonomous professionals and says another professional does not prescribe or supervise their services, while noting that some work settings and payers do require a prescription and their own eligibility criteria.⁠⁷ Federal Medicaid rules tie speech, hearing and language services to a referral, and TRICARE wants a referral or prescription before speech therapy begins.⁠^8,12 Check the state’s SLP law and each payer’s manual before telling a family no referral is needed.

Does Original Medicare need a physician order before therapy starts?

No order is required; Medicare requires a plan of care that a physician or nonphysician practitioner certifies. The Benefit Policy Manual makes certification a condition of payment, ties payment to the certified plan rather than to any order, and calls an order a prudent way to confirm a physician is involved, while the regulation says its order language requires no order for PT, OT or SLP.⁠^1,2

Three conditions travel together. The plan is set before treatment, by the treating therapist or by a physician or NPP, with the type, amount, frequency and duration of therapy, the diagnosis and the goals; the patient is under a physician’s or NPP’s care; and that practitioner certifies the plan, with recertification at least every 90 days.⁠^2,17 The clock starts on the first treatment day, with the evaluation counted as that day: a certification dated within the next 30 days is timely, and a verbal certification counts only if a signature follows within 14 days.⁠¹

Who can certify a Medicare therapy plan of care?

A physician, nurse practitioner, clinical nurse specialist or physician assistant, within limits that differ by profession and by discipline: Medicare’s conditions for OT and PT name a doctor of medicine, osteopathy or podiatric medicine as the patient’s physician, while the condition for speech-language pathology names only a doctor of medicine or osteopathy.⁠^2,18,19,20

The certifier need not be the clinician who first recommended therapy, but the manual says no physician or NPP should certify a plan for a patient who was not under some physician’s or NPP’s care at the time.⁠¹ So intake asks an adult self-referring under direct access who their physician, NP or PA is.

When can a signed referral stand in for the plan signature?

Since the start of 2025, when four things are in the record: the therapist established the plan; a physician or NPP signed and dated a written order or referral; that order identifies the practitioner and the patient and names the type of therapy; and the record proves the plan reached that practitioner no later than 30 days after the initial evaluation.⁠^2,3 With no written order or referral on file, the therapist still needs the practitioner’s signature on the plan, and the exception never reaches recertifications or plans in a comprehensive outpatient rehabilitation facility.⁠^2,3

Keep the dated proof of delivery, because the exception rests on it, and read the rule in the regulation and CMS’s September 2025 fact sheet; the manual’s certification section still carries its 2008 revision.⁠^1,3

What happens when the physician does not sign the plan in time?

Payment is at risk, and in a therapist’s own office the patient can end up owing for the visits, so send the plan the day it is written and keep evidence that you did. The manual tells therapists to forward the plan as soon as it is established, lets a contractor weigh that diligence when a certification arrives late, places a technical denial in a therapist’s office on the beneficiary, and recommends telling patients about the requirement beforehand.⁠¹ The rules for delayed certifications are in the documentation audit guide.

Does the certifying physician need to be enrolled in Medicare?

The therapy claim needs the certifier’s NPI; Medicare’s enrollment rule for ordering practitioners is written for other services. CMS’s claims manual counts the certifier as the referring provider on a professional therapy claim, and contractors check for one on claims carrying the GP, GO or GN modifier.⁠²¹ The regulation requiring an ordering or certifying practitioner to be enrolled or validly opted out, 42 CFR 424.507, covers imaging, clinical laboratory services, DMEPOS, home health and hospice, and CMS’s ordering and certifying page lists DMEPOS, laboratory, imaging and home health; outpatient therapy appears in neither.⁠^22,23 CMS sends questions about what a practitioner can certify to the MAC, so ask yours before relying on a certifier with no Medicare record.⁠²³

What do Medicare Advantage and private plans require for therapy?

Whatever each plan’s own documents say: a referral, a prior authorization, both or neither. Medicare.gov says a Medicare Advantage HMO member usually needs a referral to use a specialist, and that an approved treatment stays approved while it is medically necessary.⁠²⁴ A coordinated care plan may use prior authorization only to confirm the diagnosis or other medical criteria behind a coverage decision or, for basic benefits, medical necessity.⁠²⁵ When an adult moves between Original Medicare and a Medicare Advantage plan mid-care, ask which one pays before the next visit.

Commercial plans set their rules by product. HealthCare.gov’s definitions say a point-of-service plan requires a primary care doctor’s referral to see a specialist, a PPO member can see out-of-network providers without a referral at extra cost, and an EPO covers only in-network care outside emergencies; in many HMOs a member needs a referral to see anyone but the primary care doctor.⁠^13,26 Those describe plan types; whether a therapist counts as a specialist or therapy needs an order is in the plan documents and provider manual. Ask for the page as well as the phone answer, keep the reference number, and settle any conflict in writing.

What orders do Medicaid and EPSDT require for pediatric therapy?

Federal rules set a floor and each state writes the details in its provider manual. In the federal definitions, PT and OT are prescribed, by a physician or another licensed practitioner acting within state-law scope, while speech, hearing and language services follow a referral from such a practitioner.⁠⁸ For enrollees under 21, EPSDT adds medically necessary coverable services even beyond the state plan, judged case by case; the EPSDT guide covers that standard.⁠²⁷

Texas shows how specific a state can be. Its fee-for-service therapy handbook, October 2026 edition, lets the initial evaluation go ahead without prior authorization, though the record must hold a signed, dated order for it, and requires prior authorization for treatment, received within five business days of starting.⁠⁹ For patients 20 and younger, an order to "evaluate and treat" covers the evaluation only: the treatment order must state the prescriber’s frequency and duration, affirm that the Texas Health Steps checkup is current or a developmental screening was done in the last 60 days, and be signed within the 60 days before services begin.⁠⁹ Managed care members fall under a separate handbook.⁠⁹

Managed care plans add their own authorization steps within federal clocks: for rating periods starting on or after January 1, 2026, standard decisions within state time frames of no more than 7 calendar days, expedited ones within 72 hours, and a posted list of every item and service that needs prior authorization.⁠¹⁵ Ask for that list before the evaluation; the Medicaid enrollment guide covers joining the program and its plans.

Does an adult on Medicaid need a prescription for therapy too?

The federal wording carries no age limit: PT and OT prescribed, speech-language services referred.⁠⁸ The benefit around them changes. Texas, whose handbook covers all ages, keeps the signed order for the evaluation in its adult section and approves adult treatment in requests of no more than 60 days.⁠⁹ Read the adult section of your state’s manual on its own, and check the birth date: a 20-year-old in an adult clinic may still fall under the children’s rules.⁠^9,27

Does TRICARE need a referral for physical, occupational or speech therapy?

It depends on the plan and the discipline. TRICARE’s referral page says active duty members in Prime need a referral for any care their primary care manager does not provide, other Prime enrollees need one for specialty care and some diagnostic services, and Select and TRICARE’s other plans require one only for applied behavior analysis.⁠¹⁰ Under Prime, the referral and pre-authorization come together, the patient books with the provider named in the authorization letter, and care after the authorization expires needs approval again.⁠¹⁰

The service pages add discipline rules: OT must be prescribed and supervised by a TRICARE-authorized physician, certified physician assistant, certified nurse practitioner or podiatrist, and speech therapy needs a referral or prescription first.⁠^11,12 The PT page lists who may provide physical therapy and sends questions about limits to the regional contractor.⁠²⁸ In the West Region, TriWest takes requests through its Availity portal, with a tool showing whether one is needed.⁠²⁹ The TRICARE participation guide covers joining the network.

How do school and early intervention services handle therapy referrals?

They run on their own eligibility decisions, not on a physician’s order to a clinic. Under IDEA Part B, school OT, PT and speech-language pathology are related services the IEP team decides a child needs, and under Part C, a child under three referred to early intervention gets an eligibility evaluation by qualified personnel, with the parent’s consent.⁠^30,31 An IEP or early intervention plan does not stand in for a clinic payer’s order unless the payer’s manual says so; the IEP teams guide covers coordinating with the school.

What should a practice record for each referral requirement?

One record per patient, payer and discipline, listing each requirement with its source, so anyone on staff can see what is missing. Keep it in the clinical or practice-management system, not in a marketing or referral-source spreadsheet.

Set a follow-up time that fits the patient’s urgency and call it a practice target, not a legal deadline. When a document is missing, tell the patient rather than booking around the gap, and never bill under another clinician or reuse another patient’s order.

How should a practice request an order from a patient’s physician?

Ask a specific question through a secure route, send what the practitioner needs to decide, and leave the decision with them. HIPAA’s Privacy Rule permits disclosures for a health care provider’s treatment activities, the footing for sending an evaluation to the patient’s physician; still use a secure channel.⁠³²

Do not send a pre-filled order with a visit count to sign. Send the evaluation and the proposed plan with its frequency and duration, and ask the practitioner to certify it, change it or write their own order; where a payer requires the prescriber’s order to state frequency and duration, as Texas Medicaid does for a child’s treatment, the order states what the prescriber decided after reading the evaluation.⁠⁹ The therapist’s judgment stays independent too: ASHA’s code tells SLPs to use it when a referral source or prescription would put the patient’s welfare second, and APTA’s code asks it of physical therapists in every setting.⁠^16,33

For a child, the request usually goes to the pediatrician, and the parent hears that you are asking. For an adult, explain it directly and involve family only when the adult wants that or the person holds legal authority; the adult referrals guide covers personal representatives.

What should you check when an order or referral arrives?

Check it against the requirement you recorded, field by field, before the visit it is meant to support. If anything is unclear, ask the issuer; never alter, backdate or add a diagnosis to another clinician’s document.

What does a physician order not settle for a therapy practice?

Coverage, authorization, network status, clinical fit and capacity all stay open. An order shows that a practitioner wants the patient seen, not that the plan pays; HealthCare.gov notes that even a preauthorization is not a promise of payment.⁠¹⁴ Nor does it replace the therapist’s evaluation: under Medicare, the treating therapist may establish the plan that a physician or NPP then certifies.⁠¹⁷ Benefit verification and authorization tracking are separate steps, and the out-of-network benefits guide covers patients outside your networks.

How do you explain referral requirements to families and adult patients?

Say what is known, what is still being checked, who can get the document and whether any step has to wait, without blame. Families often hold school, early intervention and pediatric records at once; say which one helps. Adults hear it directly, with communication support where needed. For a patient with Original Medicare in a therapist’s office, add the point the manual recommends sharing: the plan needs a physician’s or NPP’s certification, and without it the patient can be liable.⁠¹ The intake call script and new patient email templates carry the rest of the conversation.

What should a website or listing say about needing a referral?

Only what the practice can support for each discipline, payer and state, with the scope stated. "No referral needed" on a PT page can be true legally and false for a patient whose plan wants one, and APTA’s code asks physical therapists for truthful, accurate information about their services, billing included.⁠^5,16 For OT and speech services, write the statement from the state act and the payers the practice bills, not from the PT rule.

A directory listing follows the same rule. On DrSensory, families search free for occupational, physical and speech therapy clinics and message a clinic from its profile; each listing covers one clinic at one address. On a paid listing the clinic’s own team reads those messages in the portal, and without a paid plan the DrSensory team tries to forward them on the family’s behalf.⁠^34,35 A family’s message is an inquiry, not a physician referral: the clinic’s intake decides which requirements apply, and DrSensory does not verify clinical quality.⁠³⁴

Which payer or pathway needs which document before therapy?

Match the patient’s payer and discipline to the rule written for it; the table is a starting map, not a substitute for the current manual.

How do a pediatric and an adult referral check play out?

In both cases the requirement record sets the order of the steps. The cases are invented; their plan and state rules are inputs, not any real policy.

How do you keep orders and certifications current during care?

Track every date that ends a document, and treat a change in the plan as a new request. For Medicare, the physician or NPP recertifies at least every 90 days or when the plan needs a significant change, may certify a shorter period than proposed, and an order for continued treatment sent during care counts as certification for the period it states.⁠^1,2 Texas Medicaid approves a child’s acute therapy in requests of up to 60 days and chronic therapy for up to 180, and adult requests for no more than 60, so renewal dates sit in the authorization.⁠⁹ TRICARE authorizations expire, and later care needs approval again.⁠¹⁰

Put each end date and the visits approved on the schedule, and check them before each booking. Keep the trail with the chart: a Medicare supplier of certified or referred services keeps the orders, certifications and referrals, with the practitioner’s NPI, for 7 years from the date of service.⁠³⁶ The documentation audit guide covers what reviewers ask to see.

Sources

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.1, Rev. 255; §220.1.1, Care of a Physician/Nonphysician Practitioner, Rev. 179; §220.1.3, Certification and Recertification, Rev. 88, issued May 7, 2008). Checked October 26, 2026.
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   “Certification is required for coverage and payment of a therapy claim.”; “Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care.”; “Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician.”; “Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.”; “It is not appropriate for a physician/NPP to certify a plan of care if the patient was not under the care of some physician/NPP at the time of the treatment or if the patient did not need the treatment.”; “Acceptable documentation of certification may be, for example, a physician’s progress note, a physician/NPP order, or a plan of care that is signed and dated by a physician/NPP”; “if during the course of treatment under a certified plan of care a physician sends an order for continued treatment for 2 more weeks, contractors shall accept the order as certification of continued treatment for 2 weeks under the same plan of care.”; “Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established.”; “Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification.”; “Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.”; “A physician/NPP may certify or recertify a plan for whatever duration of treatment the physician/NPP determines is appropriate, up to a maximum of 90 calendar days.”; “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).”; “If the order to certify is verbal, it must be followed within 14 days by a signature to be timely.”; “It is not required that the same physician/NPP who participated initially in recommending or planning the patient’s care certify and/or recertify the plans.”; “Physicians/NPPs may require that the patient make a physician/NPP visit for an examination if, in the professional’s judgment, the visit is needed prior to certifying the plan, or during the planned treatment.”; “Certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law.”; “Optometrists may order and certify only low vision services.”; “Chiropractors may not certify or recertify plans of care for therapy services.”; “Certifications are acceptable without justification for 30 days after they are due.”; “However, if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability.”; “For that reason, it is recommended that the patient be made aware of the need for certification and the consequences of its absence.”; “Payment for services provided before a plan is established may be denied.”.
2. Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (eCFR, Title 42 up to date as of October 23, 2026; paragraph (c), outpatient physical therapy, occupational therapy and speech-language pathology services). Checked October 26, 2026.
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   “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.”; “The initial certification must be obtained as soon as possible after the plan is established.”; “If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case, except as specified in paragraph (c)(5) of this section.”; “Recertification is required at least every 90 days.”; “there is a written order or referral from the individual’s physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS) in the patient’s record and the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case.”; “If there is no written order or referral from the individual’s physician, NP, CNS, or PA, in the patient’s record, the therapist must obtain the signature of the physician, NP, PA, or CNS on the plan of treatment”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.”.
3. Centers for Medicare & Medicaid Services, Medicare Learning Network. Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN Fact Sheet MLN905365, September 2025; its definitions, the section on billing Part B outpatient therapy and the section on initial plan of care certification). Checked October 26, 2026.
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   “Starting January 1, 2025, we allow the physician or non-physician practitioner (NPP) written order or referral to substitute for the signature on the initial plan of care (POC) certification”; “Physician is a doctor of medicine, osteopathy, podiatric medicine, or optometry (only for low vision rehabilitation).”; “Non-physician practitioner (NPP) is a physician assistant (PA), clinical nurse specialist (CNS), or nurse practitioner (NP).”; “POC-certifying provider’s name and NPI is on the claim”; “This applies only when the patient’s physician or NPP signs and dates the written order or referral, including information to identify the physician or NPP as well as the patient, and indicates the type of therapy needed, for example, physical therapy, occupational therapy, or speech-language pathology services.”; “along with further evidence that the POC was delivered to the physician or NPP within 30 calendar days of the therapist’s initial evaluation.”; “This policy doesn’t apply to recertifications or to POCs in a CORF.”.
4. American Physical Therapy Association. Direct Access Advocacy (APTA advocacy issue page). Checked October 26, 2026.
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   “As of July 1, 2025, all 50 states, the District of Columbia, and the U.S. Virgin Islands have either provisional or unrestricted direct access to physical therapist services for evaluation and treatment.”; “Even though patients may go directly to a physical therapist without a referral, some provisions tied to treatment absent a referral still persist in a number of states”; “Review each jurisdiction’s level of direct access to physical therapist services.”.
5. American Physical Therapy Association, ChoosePT. Physician Referral Not Needed: You Can See a Physical Therapist First (consumer page, revised March 23, 2026). Checked October 26, 2026.
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   “In every U.S. state and the District of Columbia, you can go straight to a physical therapist without a physician’s referral.”; “some health systems and insurers still have outdated policies that require a referral after a certain number of physical therapy visits or for certain treatments”; “Certain insurance plans may still require a referral. Some states may limit the duration or type of treatment that can be provided without one.”.
6. American Occupational Therapy Association. Licensure (Career: state licensure page; its list of state-by-state resources includes “Referral requirements”, which opens behind a member sign-in). “The ability to practice occupational therapy is regulated by state licensure agencies.”; “A license grants you the legal privilege to practice occupational therapy in the state in which you are licensed.”; “Referral requirements”. Checked October 26, 2026.
7. American Speech-Language-Hearing Association. Scope of Practice in Speech-Language Pathology (ASHA policy document, approved by the ASHA Board of Directors on February 4, 2016). Checked October 26, 2026.
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   “SLPs are autonomous professionals who are the primary care providers of speech-language pathology services.”; “Speech-language pathology services are not prescribed or supervised by another professional.”; “Additional requirements may dictate that speech-language pathology services are prescribed and required to meet specific eligibility criteria in certain work settings, or as required by certain payers.”.
8. Code of Federal Regulations. 42 CFR 440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (eCFR, Title 42 up to date as of October 23, 2026; Medicaid service definitions). Checked October 26, 2026.
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   “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”; “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”; “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.”.
9. Texas Medicaid & Healthcare Partnership, for the Texas Health and Human Services Commission. Texas Medicaid Provider Procedures Manual, Vol. 2: Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (October 2026 edition; sections 1, 5.1, 5.2.1, 5.2.1.1, 5.2.3 and 6.2.1). Checked October 26, 2026.
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   “This handbook contains information about Texas Medicaid fee-for-service benefits. For information about managed care benefits, refer to the Medicaid Managed Care Handbook.”; “The information in this handbook is intended for therapy services for clients of all ages.”; “This section addresses acute and chronic physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services for clients who are 20 years of age or younger.”; “Initial evaluations do not require prior authorization”; “documentation kept in the client’s record must include a signed and dated prescribing provider’s order for the evaluation, support a medical need for the therapy evaluation, and be available when requested.”; “Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated.”; “For acute therapy services, i.e. acute services billed with an AT modifier, prior authorization requests may not exceed a 60 day period per each request.”; “For chronic therapy services, prior authorization may be granted for up to 180 days with documentation of medical necessity and additional prior authorizations.”; “The prescribing provider must certify that the Texas Health Steps (THSteps) checkup is current or that a developmental screening has been performed within the last 60 days.”; “documentation kept in the client’s record must include a signed and dated prescribing provider’s order for the evaluation, support a medical need for the therapy evaluation and be available when requested.”; “The request form or written or verbal order must be signed and dated within the 60-day period before the initiation of services.”; “A prescribing provider’s order to evaluate and treat is acceptable for the evaluation or re-evaluation, but is not acceptable for the therapy treatment.”; “The therapy treatment order must contain the prescribing provider’s ordered frequency, duration, and affirmation that the client’s THSteps checkup is current or that a developmental screening has been performed within the last 60 days.”; “The verbal order must include the services, frequency, and duration that was prescribed by the ordering provider.”; “An advanced practice registered nurse (APRN) or a physician assistant (PA) may sign all documentation related to the provision of therapy services on behalf of the client’s prescribing provider when the prescribing provider delegates this authority to the APRN or PA.”; “Therapy services, regardless of place or provider, occurring after the initial evaluation, require prior authorization. Prior authorization requests may not exceed a 60 day period.”.
10. TRICARE, Defense Health Agency. Referrals and Pre-Authorizations (TRICARE beneficiary page, last updated October 7, 2026). Checked October 26, 2026.
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    “If you’re being referred, your provider will get you a referral and pre-authorization at the same time.”; “Get care before the authorization expires. Otherwise, you’ll need to get the care reapproved.”; “Book your appointment with the provider listed in the authorization letter.”; “Yes, for any care your PCM doesn’t provide.”; “Yes, for specialty care and some diagnostic services.”; “No. Only applied behavior analysis requires a referral.”; “If you see a specialist without a referral, you’re using the point-of-service option.”; “Check with your regional contractor for additional requirements and specific processes:”.
11. TRICARE, Defense Health Agency. Occupational Therapy (Is It Covered? page, last updated October 2, 2026). “Must be prescribed and supervised by any of the following TRICARE-authorized providers:”; “Physician”; “Certified physician assistant supervised by a physician”; “Certified nurse practitioner”; “Podiatrist”. Checked October 26, 2026.
12. TRICARE, Defense Health Agency. Speech Therapy (Is It Covered? page, last updated October 1, 2026). “A referral or prescription is needed before getting speech therapy services. Contact your primary care manager if using TRICARE Prime or your family provider if using TRICARE Select.”. Checked October 26, 2026.
13. HealthCare.gov, Centers for Medicare & Medicaid Services. Referral (glossary entry). Checked October 26, 2026.
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    “A written order from your primary care doctor for you to see a specialist or get certain medical services.”; “In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.”.
14. HealthCare.gov, Centers for Medicare & Medicaid Services. Preauthorization (glossary entry). “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”; “Sometimes called prior authorization, prior approval or precertification.”; “Preauthorization isn’t a promise your health insurance or plan will cover the cost.”. Checked October 26, 2026.
15. Code of Federal Regulations. 42 CFR 438.210, Coverage and authorization of services (eCFR, Title 42 up to date as of October 23, 2026; Medicaid managed care contracts, paragraphs (b), (d) and (f)). Checked October 26, 2026.
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    “For the processing of requests for initial and continuing authorizations of services, each contract must require”; “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.”; “Beginning January 1, 2026, following each calendar year it has a contract with a State Medicaid agency”; “no later than 72 hours after receipt of the request for service.”; “A list of all items and services that require prior authorization.”.
16. American Physical Therapy Association. Code of Ethics for the Physical Therapy Profession (APTA policy, dated January 1, 2026 on its policy page; standards 3.1 and 6.1 and aspirational example 3.A). Checked October 26, 2026.
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    “shall not exceed their professional, jurisdictional, and personal scopes of practice and shall communicate with, collaborate with, or refer to a peer or other health care professionals when necessary.”; “Physical therapists shall strive to demonstrate independent and objective professional judgment and make decisions in the patient’s or client’s best interests in all settings.”; “shall provide information about their services that is truthful and accurate and shall not make misleading representations in any forms of communication, including billing.”.
17. Code of Federal Regulations. 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (eCFR, Title 42 up to date as of October 23, 2026). Checked October 26, 2026.
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    “The plan is established before treatment is begun by one of the following:”; “A physical therapist who furnishes the physical therapy services.”; “A speech-language pathologist who furnishes the speech-language pathology services.”; “An occupational therapist who furnishes the occupational therapy services.”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”.
18. Code of Federal Regulations. 42 CFR 410.59, Outpatient occupational therapy services: Conditions (eCFR, Title 42 up to date as of October 23, 2026; paragraph (a)). Checked October 26, 2026.
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    “They are furnished to a beneficiary while he or she is under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.”; “They are furnished under a written plan of treatment that meets the requirements of § 410.61.”.
19. Code of Federal Regulations. 42 CFR 410.60, Outpatient physical therapy services: Conditions (eCFR, Title 42 up to date as of October 23, 2026; paragraph (a)). Checked October 26, 2026.
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    “They are furnished to a beneficiary while he or she is under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.”; “They are furnished under a written plan of treatment that meets the requirements of § 410.61.”.
20. Code of Federal Regulations. 42 CFR 410.62, Outpatient speech-language pathology services: Conditions and exclusions (eCFR, Title 42 up to date as of October 23, 2026; paragraph (a)). Checked October 26, 2026.
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    “They are furnished to a beneficiary while he or she is under the care of a physician who is a doctor of medicine or osteopathy.”; “They are furnished under a written plan of treatment that meets the requirements of § 410.61.”.
21. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04; §10.3.5, Identifying the Certifying Physician, Rev. 3367, issued October 7, 2015). Checked October 26, 2026.
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    “the National Provider Identifier (NPI) of the certifying physician/NPP identified for a therapy plan of care must be included on the therapy claim.”; “For the purposes of processing professional claims, the certifying physician/NPP is considered a referring provider.”; “Contractors shall edit to ensure that there is at least one claim-level referring provider identified on professional therapy claims”; “shall use the presence of the therapy modifiers (GN, GP, GO) to identify those claims subject to this requirement.”.
22. Code of Federal Regulations. 42 CFR 424.507, Ordering covered items and services for Medicare beneficiaries (eCFR, Title 42 up to date as of October 23, 2026; paragraphs (a) and (b)). Checked October 26, 2026.
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    “Conditions for payment of claims for ordered covered imaging and clinical laboratory services and items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)”; “Conditions for payment of claims for covered home health and hospice services.”.
23. Centers for Medicare & Medicaid Services. Ordering & Certifying (Medicare enrollment page, last modified March 27, 2026). Checked October 26, 2026.
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    “Be enrolled in Medicare in either an "approved" or an "opt-out" status”; “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)”; “Clinical Laboratory Services”; “Imaging Services”; “Home Health Services”; “Contact your MAC (PDF) if you have questions about what you can order and certify.”.
24. Medicare.gov, Centers for Medicare & Medicaid Services. Health Maintenance Organizations (HMOs) (Medicare Advantage plan type page). Checked October 26, 2026.
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    “In most cases, you have to get a referral to use a specialist in HMO Plans.”; “If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary.”; “If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment.”.
25. Code of Federal Regulations. 42 CFR 422.138, Prior authorization (eCFR, Title 42 up to date as of October 23, 2026; Medicare Advantage). Checked October 26, 2026.
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    “Prior authorization processes for coordinated care plans may only be used for one or more the following purposes:”; “To confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service; or”; “For basic benefits, to ensure an item or service is medically necessary based on standards specified in § 422.101(c)(1)”.
26. HealthCare.gov, Centers for Medicare & Medicaid Services. Health insurance plan & network types: HMOs, PPOs, and more (plan type definitions). Checked October 26, 2026.
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    “POS plans require you to get a referral from your primary care doctor in order to see a specialist.”; “You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.”; “A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).”.
27. Medicaid.gov, Centers for Medicare & Medicaid Services. Early and Periodic Screening, Diagnostic, and Treatment (Medicaid benefit page). Checked October 26, 2026.
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    “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.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”; “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.”; “Necessary referrals should be made without delay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation.”.
28. TRICARE, Defense Health Agency. Physical Therapy (Is It Covered? page, last updated October 1, 2026). “TRICARE covers physical therapy when:”; “Professionally administered to aid in the recovery from disease or injury”; “Contact your regional contractor for specific limitations to the physical therapy benefit.”. Checked October 26, 2026.
29. TriWest Healthcare Alliance, TRICARE West Region contractor. TRICARE Referral and Authorization Guidelines (provider page). Checked October 26, 2026.
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    “Use the Online Referral Management System on provider portal, Availity to submit and view TRICARE West Region referrals and authorizations.”; “Ensure the requesting provider is the same provider to whom the referral was authorized.”; “Log in to the provider portal, Availity to use the Referral and Authorization Decision Support tool.”.
30. Code of Federal Regulations. 34 CFR 300.34, Related services (eCFR, Title 34 up to date as of October 23, 2026; IDEA Part B). “includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy”; “that are determined by the IEP Team to be necessary for the child to receive FAPE.”. Checked October 26, 2026.
31. Code of Federal Regulations. 34 CFR 303.321, Evaluation of the child and assessment of the child and family (eCFR, Title 34 up to date as of October 23, 2026; IDEA Part C). Checked October 26, 2026.
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    “each child under the age of three who is referred for evaluation or early intervention services under this part and suspected of having a disability, receives”; “Evaluation means the procedures used by qualified personnel to determine a child’s initial and continuing eligibility under this part”; “subject to obtaining parental consent in accordance with § 303.420(a)(2)”.
32. Code of Federal Regulations. 45 CFR 164.506, Uses and disclosures to carry out treatment, payment, or health care operations (eCFR, Title 45 up to date as of October 23, 2026; HIPAA Privacy Rule). “A covered entity may disclose protected health information for treatment activities of a health care provider.”. Checked October 26, 2026.
33. American Speech-Language-Hearing Association. Code of Ethics (ASHA policy, effective March 1, 2023). “Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative directive, referral source, or prescription prevents them from keeping the welfare of persons served paramount.”. Checked October 26, 2026.
34. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 26, 2026.
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    “Families search it for occupational, physical and speech therapy near them, read profiles and send messages.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “On a paid listing, your team does, in the portal; the email you receive only says a message is waiting.”; “On a listing without a paid plan, the message comes to the DrSensory team, who try to reach the clinic by forwarding it on the family’s behalf”; “DrSensory does not verify clinical quality, and says so on every results page.”.
35. DrSensory. Therapy Clinic Directory Pricing (the pricing page). “Families never pay to search or to contact you.”; “Or $349.99 a year. Each additional location is $9.99 a month or $99.99 a year.”; “We do not verify clinical quality.”; “We do not sell your leads.”. Checked October 26, 2026.
36. Code of Federal Regulations. 42 CFR 424.516, Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program (eCFR, Title 42 up to date as of October 23, 2026; paragraph (f)). Checked October 26, 2026.
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    “A provider or a supplier that furnishes covered ordered, certified, referred, or prescribed Part A or B services, items or drugs is required to”; “Maintain documentation (as described in paragraph (f)(1)(ii) of this section) for 7 years from the date of service; and”; “The documentation includes written and electronic documents (including the NPI of the physician or, when permitted, other eligible professional who ordered, certified, referred, or prescribed the Part A or B service, item, or drug) relating to written orders, certifications, referrals, prescriptions, and requests for payments”.

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. State practice acts and each payer’s current policy govern a specific patient, and its cases are hypothetical, not DrSensory data or real patients.