> For the complete documentation index, see [llms.txt](https://docs.pravatherapy.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://docs.pravatherapy.com/compliance-insurance-billing.md).
# Compliance / Insurance Billing
## Prior Authorization
Prava fully manages prior authorizations on your behalf. This section explains how the process works, what to expect from us, and how to track authorization status in the system.
**How It Works**
When a new client case is created, our team automatically checks whether prior authorization is required based on the client's insurance plan. If authorization is needed, we will submit the request, monitor its status, and notify you at every key step via email. You do not need to initiate or follow up on authorization requests — our team handles this end to end.
**If you add a new patient or case and you don't hear from us on authorizations, you're good to go.** For plans that never require authorization (such as Medicare Part B), or cases where authorization is already in place before the client starts care, we won't send any authorization emails. No news is good news.
Authorization emails go to everyone on the care team for each case. We know this may not always be the right setup and we have plans to improve on this in the near future.
**Authorization Scenarios**
Depending on the client's insurance plan, one of the following scenarios will apply:
1. **Authorization is required before the initial evaluation:** You will receive an email asking you to hold the evaluation until authorization is approved. Do not evaluate or treat the patient until you hear from us that authorization has been approved.
2. **Authorization is required after the initial evaluation, before treatment:** You will receive an email confirming you may proceed with the initial evaluation, but that you must hold treatment until authorization is approved. Please limit the evaluation note to evaluation CPT codes only — do not add treatment CPT codes to the evaluation note. Once you sign and lock the evaluation note, our team will use it to submit the authorization request. You'll receive a follow-up email reminding you to hold treatment, and another once authorization is approved.
3. **Authorization is required after a set number of visits:** Some plans allow a limited number of visits before authorization is needed. You will receive an email telling you how many visits are approved upfront, and our team will automatically request authorization before that limit is reached. You'll be notified once the new authorization is approved.
4. **No authorization required:** No email will be sent. You may proceed with care.
**Re-Authorization & Authorization Extensions**
When an existing authorization is approaching its visit limit or end date, our team will request a re-authorization. Depending on the payer, this may result in a brand new authorization or an extension of the existing one (adding more visits, more time, or both). Either way, you will receive an email with the updated authorization details and a reminder of how many visits remain. If visits run out before a new authorization is approved, you will receive an email asking you to hold treatment until we confirm approval.
If a patient is being discharged or will not be continuing care, please let us know as soon as possible by submitting a discharge note or reaching out to . This helps us avoid requesting unnecessary re-authorizations on the patient's behalf. If we learn that a patient is no longer continuing care, we will cancel the outstanding authorization request.
**Checking Authorization Status in the System**
You can see the current authorization status and completed visits directly in the system in two places:
1. **Client Profile → Billing / Insurance:** This tab shows the active authorization record for the client, including the authorization number, start and end dates, the associated case, and how many visits have been completed so far.
2. **Chart Notes:** When you start a new note, you will see how many visits have been completed to date for the client, giving you a quick reference before each session.
Note that a visit is considered completed **only when a chart note is signed** for that session.
## Referral Orders & Care Plan Signatures
The majority of insurance plans **do NOT require a referral** to start physical therapy and so we do not require one to start care unless the insurance plan requires it (which we will tell you about). Each state also has its own set of direct access rules (see [here](https://www.apta.org/contentassets/4daf765978464a948505c2f115c90f55/direct-access-by-state-map.pdf)) that we monitor and will inform you about if a referral is needed to continue care.
For Medicare and Managed Medicare plans, we are **required to get the care plan signed off** by a referring physician. This acts similar to a referral and a referral can in some cases replace a signed care plan, but the signed care plan is the stronger compliance requirement and the one we focus on over referrals. After submitting an evaluation or recertification note on the platform we will automatically fax that over to the referring physician on file and follow up with them to get a signature back within 30 days. See [here](https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r88bp.pdf) for more details on this requirement from CMS.
## Can I see a patient for multiple conditions? How should I document that?
If a patient has multiple unrelated conditions you have 2 different options to document:
1. You can combine both on the same care plan/case and treat together. This option will require a single combined Eval and will send out a single combined care plan to the referring provider. You would typically treat both during the same treatment session and document in a single treatment note.
2. You can create [separate cases](/client-cases.md) and treat each independently. This option will have you submit separate evals (done on different dates of service) and have distinct treatment sessions for each case. Note that it is **important** to NOT do multiple treatments on a single date of service if both are being billed to insurance.
## Can I see a patient if they are receiving outpatient therapy by another provider?
Yes — Medicare does not prohibit a beneficiary from receiving outpatient physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) services from more than one provider, ***as*** **long as each service is distinct (e.g. different diagnose), medically reasonable and necessary and complies with CMS coverage criteria, documentation, and billing requirements***.* Medicare Part B outpatient therapy coverage rules do not include a restriction that a beneficiary must receive all outpatient therapy services from only one provider or clinic. For the core policy on outpatient therapy coverage, see [CMS Medicare Benefit Policy Manual, Chapter 15, §220 – Coverage of Outpatient Rehabilitation Therapy Services.](https://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/bp102c15.pdf?utm_source=chatgpt.com)
## Can I see a patient if they are on palliative care?
Yes, as long as they are [not in hospice](#can-i-see-a-patient-if-they-are-in-hospice), a patient being on palliative care does not have any impact on billing Medicare Part B.
## Can I see a patient if they are in hospice?
When a Medicare beneficiary elects hospice under Medicare Part A, they **waive Medicare Part B payment rights** *for services related to their terminal illness and related conditions*, but Medicare Part B continues to cover medically necessary outpatient services for conditions that are **unrelated to the hospice diagnosis** if there’s an appropriate physician order and the services meet usual Medicare Part B requirements. In practice, this means you *can* bill Medicare Part B for outpatient PT for a hospice patient *if the PT is treating a non-hospice-related condition* and is medically necessary, with documentation supporting that distinction. See [Hospice Care on the CMS Site](https://www.medicare.gov/coverage/hospice-care) for more information.
Note that if a patient has a Managed Medicare plan (i.e. through a commercial insurance like United, BCBS, etc.) the payer shifts back to original Medicare during the hospice election period. So we would bill original Medicare, not the managed medicare plan.
## Can I see a patient if they have an active home health episode
Yes. Patients receiving home health services may still participate in additional PT, OT, or SLP visits on a private-pay basis, provided those visits are wellness-focused and are not billed to insurance.
Examples of appropriate wellness goals include:
* Maintaining mobility and strength
* Improving general fitness or endurance
* Supporting balance, flexibility, or quality of life
* Preventative or maintenance-focused exercise programs
These visits should remain clearly separate from the skilled rehabilitation services being provided through the patient’s home health plan of care.
Because wellness visits are private pay and not submitted to insurance, documentation requirements are lighter than standard skilled therapy documentation. Basic session notes describing the services provided are sufficient.
## How are providers paid for Auto Insurance (MVA) cases?
Prava supports auto insurance cases for our providers. However, because payment timelines can be lengthy and reimbursement amounts are often uncertain until the claim is fully resolved, we are unable to provide payment guarantees on these cases. Provider payments are issued only after the adjuster has finalized and paid the claim, which in some cases can take a year or longer.
## Can Prava waive/reduce the copay for my patient?
In general, providers are expected to make a **good-faith effort to collect copays, coinsurance, and deductibles**. You may only waive or reduce patient responsibility in limited situations—primarily when a patient demonstrates **genuine financial hardship**, or after reasonable collection efforts have failed. Federal guidance (including from the Centers for Medicare & Medicaid Services and HHS OIG) makes clear that any waiver must be **individualized, documented, and not routine**. [CMS Medicare Claims Processing Manual](https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c18pdf.pdf?utm_source=chatgpt.com). Not following this can violate payer contracts and federal laws (including the Anti-Kickback Statute and False Claims Act),
If you have a case where you believe your patient demonstrates genuine financial hardship, please reach out to with the following information and we’ll review your case and let you know if an accommodation is warranted:
* Name of patient
* Reason for hardship (e.g. loss of employment or reduced income, high medical expenses, unable to afford basic living expenses, temporary financial hardship (e.g., recent life event)). A generic category is *not sufficient* - specific details are needed
* Support requested: (e.g. waiving/reducing copay by $X? Is it one-time, ongoing?)
If your case is approved, the payment reduction will be reflected in your payout.
## What is the full session cost from a patient perspective?
The costs depends on two factors:
1. What services you are billing
2. What the specific insurance’s allowed amount is for those services
In our cost estimates we say that a session typically costs between $120 and $180. Here are some other rough numbers to give you a more specific idea for your particular situation:
* A eval code is typically around $80 - $100 on it’s own
* Each billable unit of treatment is around $20 - $30/unit
* Some payers have a flat per visit rate (e.g. United, Cigna, Blue Cross/Anthem in CA) in which case the patient’s cost will be capped similarly
## How does out of network billing work?
Out of network billing is when you are billing a patient’s insurance plan, but are not credentialed with that insurance plan. There are 2 ways that this can work:
1. You can charge the patient a standard cash pay rate for each session and then we can provide them with a [Superbill](#what-is-a-superbill) that they can submit to their insurance company for reimbursement. In this case you determine the per session fee and get paid out as a normal cash pay session.
2. We can bill the insurance company directly the same as we would bill any in-network services. In this case, we must follow the insurance company’s allowed amounts and your payout will follow your fee schedule.
You can choose which option you’d like on a per client basis. **By default, Prava will assume we’re following option 2** if you are provided with out of network benefits during the intake process. If you’d like to follow option 1, make sure to let us know you’d like to switch the patient to cash pay.
The first approach typically leads to higher reimbursement per session, but puts more work on the patient to submit to insurance and try and get some reimbursement. The second option works exactly the same as in-network billing, so is better from a patient perspective, but leads to lower reimbursements.
## What is a Superbill
A Superbill is a receipt for a service provided that has all the information needed for an insurance company to determine how much it will reimburse the client for that session. A standard receipt may only have the session date and amount, but a Superbill will contain additional fields like diagnosis codes, billing codes that the insurance company needs in order to calculate things like copays and deductibles.
These are typically used when a patient is coming in and paying cash for their sessions, but plans on submitting their receipts to their insurance company to try and get some portion of the costs covered.
## Progress Notes v. Recerts v. Re-evals
Progress note (“progress report”)
* Non-billable summary of progress and medical necessity for continued care. Required for audits; commonly used to support prior-auth extensions.
* At least every 10 treatment days or every 30 calendar days (whichever is less). We follow this standard across payers.
* Note that the time spent documenting / re-assessing measures/outcomes is NOT billable by insurance companies. Most providers do their progress notes as part of a regular treatment session in order to still bill out the treatment codes. Re-eval codes (e.g. 97164) are NOT intended to be used here (see below).
* See [Progress Notes](/charting.md#progress-notes) on how to submit in the platform.
Recertification of the Plan of Care (“recert”)
* Non-billable renewal of the plan of care when the current certification period ends or the plan is significantly modified; must be signed/dated by a physician or NPP.
* Initial certification signed within 30 days of first treatment; recert at least every 90 days from treatment start or when the plan changes.
* Note that the time spent documenting / re-assessing measures/outcomes is NOT billable by insurance companies. Most providers do their recert notes as part of a regular treatment session in order to still bill out the treatment codes. Re-eval codes (e.g. 97164) are NOT intended to be used here (see below).
* See [Recertification Notes](/charting.md#recertification-notes) on how to submit in the platform.
Re-evaluation (PT 97164)
* Billable only when there is a significant, non-routine change (new findings, meaningful status change, or lack of expected response) that requires new tests/measures and a revised plan of care—not for routine updates, progress notes, or recerts.
* These should be submitted Eval notes in the platform.
[CMS Documentation](https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57067\&ver=29&=)
## AMA vs. CMS Billing
*Note: We handle all of the below details on your behalf, so you don’t have to worry about mastering the nuances here. But there are important implications of these methods to help optimize your coding practices that are good to be familiar with.*
There are two methods to convert a set of CPT codes + durations into a set of codes + units that are very similar but have an important difference:
AMA Billing
* Mainly used by commercial payers and generally results in the ability to bill a higher number of units for the same length session compared to CMS
* You simply convert each duration into the associated number of minutes following the “8-minute rule”
* This allows you to bill in aggregate an extra unit in some cases. For example, for a 1 hour session:
* 10 minutes of 97110 -> 1 unit
* 24 minutes of 97140 -> 2 units
* 26 minutes of 97530 -> 2 units
* \== 5 units total for a 1 hour session
CMS Billing
* Used by Medicare and Managed Medicare plans
* See Section 20.2 in the [CMS Manual](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c05.pdf)
* You have to first add up all of the durations across all codes for the session and convert that number that a an overall units number for the entire session
* Then you spread those units over the codes with the potential extra code going to the longest duration activity
* In this case you are never able to bill more than 4 units for an hour session. Using our previous example:
* 10 minutes of 97110
* 24 minutes of 97140
* 25 minutes of 97530
* Is 60 total minutes -> 4 units, so you would bill:
* 1 unit of 97110, 1 unit of 97104 and 2 units of 97530 (this one gets an extra b/c it’s the longest activity)
8 Minute Rule Table
* \> 7 minutes and <= 22 minutes: 1 unit
* \> 22 minutes and <= 37 minutes: 2 units
* \> 37 minutes and <= 52 minutes: 3 units
* \> 52 minutes and <= 67 minutes: 4 units
* … and so on…
## Group Therapy Billing Guidelines
The CPT code 97150 is used to bill for group therapeutic procedures, meaning a therapist supervises a structured therapy session involving two or more patients simultaneously. You must submit a separate note for each individual patient treated in the group. This code is untimed (you bill one unit per patient, regardless of actual minutes of the session) and typically reimburses around $15 per unit in outpatient physical-therapy settings.
Documentation must clearly reflect the medical necessity of the group format rather than individual therapy, describe the therapist’s role in supervising the group rather than providing exclusive one-on-one contact, list the number of patients in the group, describe the group activity and each patient’s participation/response, and tie it to the patient’s plan of care. Best practice is to limit the group size to no more than 10 participants to ensure adequate supervision and justification for using the group therapy code.
---
# Agent Instructions
This documentation is published with GitBook. GitBook is the documentation platform designed so that both humans and AI agents can read, navigate, and reason over technical content effectively. Learn more at gitbook.com.
## Querying This Documentation
If you need additional information that is not directly available in this page, you can query the documentation by asking a question.
Perform an HTTP GET request on the following URL with the `ask` and `goal` query parameters:
```
GET https://docs.pravatherapy.com/compliance-insurance-billing.md?ask=&goal=
```
`ask` is the immediate question: it should be specific, self-contained, and written in natural language.
`goal` is what the user is ultimately trying to achieve, the reason they need the answer. Sharing it helps GitBook give you a better, more relevant answer. A goal is most helpful when it describes the outcome the user wants rather than restating the question. For example, with `ask=how do I create an API token`, a goal like `automate deployments from our CI pipeline` lets GitBook tailor the answer to that use case.
The response will contain a direct answer to the question and relevant excerpts and sources from the documentation.
Use this mechanism when the answer is not explicitly present in the current page, you need clarification or additional context, or you want to retrieve related documentation sections.