Physical therapist (PT) in private practice

Qualification requirements

Physical therapists (PT) who are in private practice must meet the following applicable criteria to provide services for Medicare beneficiaries:

• Graduated after successful completion of a physical therapist education program approved by one of the following:
  
  • The Commission on Accreditation in Physical Therapy Education (CAPTE).
    

  • Successor organizations of CAPTE.
    

  • An education program outside the United States determined to be substantially equivalent to physical therapist entry-level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association (APTA) or other approved organization as it relates to physical therapists; and
    

  • Passed an examination for physical therapists approved by the state in which physical therapy services are provided

or

• On or before December 31, 2009 -
  
  • Graduated after successful completion of a physical therapy curriculum approved by the CAPTE; or
    

  • Meets both of the following:
    
    • Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a credentialed evaluation organization approved by the APTA or other approved organization as it relates to physical therapists; and
      

    • Passed an examination for physical therapists approved by the state in which physical therapy services are provided

or

• Before January 1, 2008 -
  

• Graduated from a physical therapy curriculum approved by one of the following:
  
  • The APTA.
    

  • The Committee on Allied Health Education and Accreditation of the American Medical Association.
    

  • The Council on Medical Education of the American Medical Association and the APTA

or

• On or before December 31, 1977, was licensed or qualified as a physical therapist and meets both of the following:
  
  • Has two years of appropriate experience as a physical therapist.
    

  • Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service

or

• Before January 1, 1966 -
  
  • Was admitted to membership by the APTA; or
    

  • Was admitted to registration by the American Registry of Physical Therapists; or
    

  • Has graduated from a physical therapy curriculum in a four-year college or university approved by a state department of education

or

• Before January 1, 1966, was licensed or registered, and before January 1, 1970, had 15 years of full-time experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy.
  

Documentation requirements and recommendations

Providers must submit an enrollment application by:

• Completed CMS-855I form
• Signed and dated certification statement:
  • The signature of the individual practitioner must be a handwritten signature (original signature not required)
  • Digital signatures (DocuSign or other software) are acceptable
  • A copy of the signature is acceptable; however, no stamped signatures can be accepted

or

• Completed web application using PECOS:
• Signed and dated certification statement of PECOS web application by:
  • E-signing electronically or
  • Uploading a signed and dated paper certification statement

and

• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) or its equivalent in PECOS:
  • Must include associated documentation (e.g., copy of a voided check or account confirmation letter on bank letterhead)
• If a provider already receives payments via EFT and is not making a change to banking information, the EFT is not required
• Physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588
• Read CMS-588 Electronic funds transfer (EFT) for more information

Additional documentation requirements (when applicable)
Medicare may require additional documentation, when applicable, to validate key information submitted on the enrollment application or to address specific issues that could affect a practitioner’s potential eligibility for enrollment unfavorably (e.g., adverse legal actions).

Include copies of the following supporting documents, if applicable:

• Copy of practitioner’s state medical license if not verifiable online
• Copy of certification if not verifiable online
• Certificate of completion, transcript, or diploma from accredited educational program(s) if requested
• IRS document verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)
  • Applies to clinics, groups, organizations, and institutional providers
• Final adverse legal action documentation:
  • Include copies of legal documents associated with any final adverse action(s) taken against the provider
  • Include copies of any legal documents showing the resolution (e.g., notifications, reinstatement letters)
• Completed Medicare Participating Physician or Supplier Agreement (CMS-460), if applicable:
  • A participating provider is one who bills Medicare directly and accepts assignment for covered services as payment in full
  • Physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-460

Good Standing Letter (GSL) – When there is no online source to verify a provider’s medical license in the U.S. Virgin Islands or Puerto Rico, the provider/supplier must supply a Good Standing Letter (GSL) or 120-Day Certification Letter from the State/Territory licensing authority:

• A copy of the GSL or 120-Day Certification Letter issued by the State/Territory licensing authority must be submitted with each application received for initial enrollment, reactivations, revalidations, and change of information applications involving a license update/change
• The GSL may have multiple names listed on the letter to show an active medical license
• The GSL is valid if it was issued within:
  • 6 months of receiving the application for U.S. Virgin Islands
  • 12 months of receiving the application for Puerto Rico