Physical Therapy Authorization and Approval Guidance Effective January 31, 2026

To ensure Healthfirst members receive quality, consistent, and timely care, a provider questionnaire has been introduced to accompany the initial prior authorization request for Adult Physical Therapy. This enhancement is designed to streamline approvals and ensure that members are placed on the most appropriate care pathway by providing Healthfirst with additional targeted information needed to make an appropriate clinical decision. These changes apply to members enrolled in any of Healthfirst’s plans, including Medicaid, Medicare, Essential Plans, and Qualified Health Plans.

Key Changes

• Initial provider questionnaire
• Adult Acute & Chronic diagnosis care pathway
• Approval units with no clinical review
• Clinical Documentation Alignment: Medical records should reflect the proposed plan of care consistent with the needs of the member, diagnosis and request for service(s)

Adult Acute & Chronic Diagnosis Care Pathway

Each request will be categorized into one of two pathways — acute or chronic diagnosis.

Acute diagnoses: Short-term or post-incident care: Up to 10 units (visits) will be automatically approved without the need for clinical review. Examples of acute diagnoses are listed below:

• Post injury, accident, trauma, or CVA
• Post-operative care (within 90 days)
• Post-hospitalization (within 60 days)
• Post-SNF or acute rehab (within 60 days)

Chronic diagnoses: Long-term or recurring condition: Up to 5 units (visits) will be automatically approved without the need for clinical review. Examples of chronic diagnosis are listed below:

• Pain diagnosis related to an exacerbation/flare-up of a prior condition
• Pain diagnosis related to a chronic condition (e.g., osteoarthritis)

To streamline the authorization process, initial therapy requests up to 10 units (visits) for acute diagnoses and 5 units (visits) for chronic diagnoses will not be subject to Utilization (Clinical) Review. These requests will be automatically approved up to these threshold amounts.

Pediatric Care

To streamline the authorization process, initial therapy requests up to 20 units (visits) will not be subject to Utilization (Clinical) Review. These requests will be automatically approved up to these threshold amounts.

Utilization Review

Requests for initial or continued therapy beyond these thresholds are subject to Utilization Review. To facilitate this review, please submit the following documentation:

• Physician order
• Initial evaluation
• Proposed plan of care

Utilizing the auto-approval pathways for the above noted threshold amounts allows for faster turnaround times and minimizes administrative burdens, ensuring that members receive timely access to needed care. Requests requiring clinical review may extend processing times and are subject to additional documentation requirements.

This process supports efficient care coordination and upholds Healthfirst’s commitment to delivering high-quality, medically necessary services for our members.

What Providers Need to Do

• Utilize Availity Essentials for more efficient and timely submission
• Complete the provider questionnaire during the initial request
• Ensure all supporting documentation reflects the plan of care consistent with the diagnosis type

Frequently Asked Questions

Is prior authorization required for the initial evaluation?

Prior authorization is not required for the initial evaluation.

Is clinical documentation required on the initial request?

The following clinical documentation is required only if the request goes beyond the allowable units.

• Order (Prescription from primary care practitioner (PCP) or other non-physician practitioner (NPP) 
• Initial evaluation
• Proposed plan of care

What if the member needs additional therapy after the initial visits?

If additional visits are needed provider will submit a request for continuous care. Clinical documentation will be required for additional requests. 

For additional visits for new diagnosis or body part, the following clinical documentation is required:

• Order /prescription from primary care practitioner (PCP) or other non-physician practitioner (NPP)
• Initial evaluation

What happens if not all clinical documents are submitted upon request?

This may delay your request and a request for more information will be sent to the rendering provider. Submission of clinical information is highly recommended to facilitate quicker processing of request.

How are services or additional visits requested?
For faster submissions, providers may submit prior authorization requests using the Online Authorization Tool located in the Availity Essentials Provider Portal.

Additional Resources

• Submit Prior Authorization Requests Online through Availity Essentials™
• Online Authorization Tool Guide

Questions?

For all other questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).