CurrentMolina HealthcarePolicy N/A

Outpatient therapy reimbursement (PT/OT/ST)

Defines Molina Healthcare's reimbursement approach and limits for physical therapy, occupational therapy, and speech therapy services and notes state exceptions; applies to Molina providers billing for these therapy services.

Policy Summary

PayerMolina Healthcare

PolicyOutpatient therapy reimbursement (PT/OT/ST)

Policy CodePolicy N/A

Change TypeTemplate and overview/references revisedinitial creation recorded

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization before delivering therapy services that would exceed the annual service limit.

SourceLink

POLICY UPDATE CHANGES

Updated Template; revised Policy Overview section; revised Reference section; refreshed hyperlinks.

Updated Initial Creation Date

Initial Creation Date recorded as 09/08/2023 and New Policy.

annual limittherapy services maximum cannot be exceeded without authorization

AZ, FL, KY, WAstates with specific deviations

09/08/2023policy creation date

08/19/2025last revised date

Reimbursement and Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General reimbursement criteria

Reimbursement for outpatient physical therapy (PT), occupational therapy (OT), and speech therapy (ST) is provided according to applicable state and federal guidelines and the provider contract; annual service limits apply and state-specific exceptions are noted.

Reimbursement follows applicable state and federal guidelines and the member's benefit plan document; provider contract language prevails in the event of conflict.

Services covered by this policy include outpatient PT, OT, and ST, and reimbursement will be consistent with nationally accepted industry standards and coding principles used to develop this policy.

Annual service limits: Physical therapy, occupational therapy, and speech therapy services must not exceed the annual service limit maximum without obtaining proper authorization.

Authorization required when annual limits would be exceeded; see prior authorization procedures per state/contract.

State exceptions (examples)

Arizona: Speech therapy while inpatient (hospital, nursing facility, custodial care) is covered when ordered by PCP or attending physician; outpatient speech covered for members under 21 and ALTCS members. Occupational and physical therapy received while inpatient do not count toward the maximum units per contract year.
Florida: Skilled Nursing Facility inpatient services do not count toward the 35-visit yearly limit.
Kentucky: Per the COVID authorization waiver, services rendered in inpatient or outpatient settings did not require authorization for dates of service 08/11/2021–04/30/2022; see state resources for current rules.
Washington: Members age 20 years and younger are excluded from therapy benefit limitations; HCA does not place limitations on therapy benefits for members <= 20 years of age.

Coding and billing: Codes listed in the policy are for reference only and may not be all-inclusive; coverage is determined by the benefit document and providers must follow industry-standard coding practices.

Deleted or inactive codes may not be eligible for reimbursement; improper billing may result in denial or recovery of payments.

Coding and Limits

Coding disclaimermixed

Policy includes coding disclaimer; codes listed are for reference and not all-inclusive.

Annual service limit

Annual service limitTherapy services (PT/OT/ST) must not exceed the annual service limit maximum without obtaining proper authorization.

ApplicabilityLimit applies subject to applicable state, federal, and provider contract rules.

Authorization requirementProper authorization must be obtained before reimbursement for services that would exceed the annual limit.

Reimbursement consequenceMolina Healthcare will reimburse in accordance with state, federal, and provider contracts; services beyond limits require authorization to be covered.

Prior Authorization & Provider Requirements

Prior Authorization

Authorization for services exceeding annual limits

Authorization required for services exceeding annual maximums. Physical therapy, occupational therapy, and speech therapy that would exceed the plan's annual service-limit maximum must have prior authorization before reimbursement will be provided. Molina Healthcare will reimburse only in accordance with applicable state, federal, and provider contract requirements.

A prior authorization must be obtained when projected services will exceed the member's annual limit.
Authorization is required regardless of setting (inpatient/outpatient) unless a specific state exception applies (see state exceptions).
Claims submitted without required authorization may be denied or subject to contract/state rules for retroactive approvals.

Note

State exception authorization notes

State-specific exceptions may alter authorization or counting of services toward annual limits. Certain states have exceptions where therapy provided in specific settings or to specific populations does not require authorization or does not count toward the annual maximum — verify state rules before requesting or billing authorization.

AZ: Speech therapy provided to members receiving inpatient care at a hospital, nursing facility, or custodial care facility when ordered by the PCP or attending physician is covered. Outpatient speech therapy is covered only for members under age 21 and ALTCS members. Occupational and physical therapy services received while inpatient at a hospital, nursing facility, or custodial care facility do NOT count toward the maximum allowed units per contract year.
FL: Skilled Nursing Facility inpatient services do NOT count toward the 35-visit yearly limit.
KY: Per the COVID authorization waiver, services rendered in an inpatient or outpatient setting did not require authorization for dates of service 08/11/2021–04/30/2022 (historic waiver; verify current requirements).
WA: Members age 20 and younger (<=20) are excluded from therapy benefit limitations — HCA does not place limitations for members 20 years and younger.

Therapy Service Definitions

Physical Therapy (PT) — definition and scope

DefinitionPhysical therapists are healthcare professionals who help individuals regain or improve physical function, mobility, and strength.

Conditions treatedMusculoskeletal and neuromuscular conditions; rehabilitation after injuries, surgeries, arthritis, stroke, sports injuries, and chronic pain.

InterventionsExercises, manual therapy, modalities (heat, cold, ultrasound), and other techniques to reduce pain and enhance mobility.

SettingsProvided in hospitals, outpatient clinics, rehabilitation centers, schools, and home settings.

Occupational Therapy (OT) — definition and scope

DefinitionOccupational therapists help individuals develop or regain skills needed for daily life activities (self-care, work, school, leisure).

Conditions treatedPhysical, cognitive, developmental, or psychological conditions affecting participation in daily activities.

InterventionsAssessment of abilities and environment; interventions may include adaptive equipment and environmental modifications to improve independence and quality of life.

SettingsServices provided in hospitals, schools, rehabilitation centers, mental health facilities, and home-based settings.

Speech Therapy (ST) — definition and scope

DefinitionSpeech-language pathologists (SLPs) diagnose and treat communication and swallowing disorders across the lifespan.

Conditions treatedSpeech sound disorders, language disorders, voice disorders, fluency disorders (stuttering), and swallowing disorders (dysphagia).

InterventionsTherapies to improve speech production, language skills, voice quality, communication strategies, and swallowing safety.

SettingsServices provided in hospitals, schools, rehabilitation centers, private practices, and nursing homes.