A physical therapy referral is a written order from a physician or other authorized healthcare provider that authorizes a patient to begin physical therapy treatment. This document is often required by state law or by health insurance payers to ensure the medical necessity of the treatment before covering the cost. The validity period of this referral is not a fixed, universal number, but rather a variable duration determined by a combination of factors. Understanding the specific rules that govern this timeframe is necessary to ensure continuous, covered care.
Standard Timeframes for Referral Validity
The typical lifespan of a physical therapy referral often falls within a range of 30 to 90 days from the date it was issued. This initial timeframe is generally the period during which the patient must begin the authorized treatment. If the patient does not start therapy within this window, the referral may expire, and a new one may be needed before the first appointment.
A referral may specify the duration of treatment in terms of a set number of visits (e.g., 6, 10, or 12 sessions) instead of a time period. In this case, the referral remains valid until the patient completes the specified number of appointments. Alternatively, the referring provider might specify a duration of care, such as “physical therapy twice a week for six weeks,” and the referral is valid until that time or those visits are exhausted.
It is important to distinguish between the referral and the authorization, which is the official approval from the insurance company to pay for the care. The referral is the physician’s order for treatment, often including details like the frequency and duration of therapy. The authorization is the payer’s confirmation of coverage, and its expiration date is the hard limit on when the insurer will stop paying for services, regardless of the physician’s initial order.
Key Factors That Influence Referral Expiration
The most significant factor determining the practical expiration of a physical therapy referral is the specific policy set by the patient’s insurance or third-party payer. The insurer sets the hard limit on the authorization period, which dictates the referral’s practical lifespan for covered services. For example, a physician might write a referral for three months, but the insurance company might only authorize payment for the first 30 days or the first six visits.
Different types of insurance plans have varying rules. Many private insurers may allow direct access to a physical therapist but still require authorization for payment. Government programs like Medicare and Medicaid also have complex rules, with Medicaid policies varying widely by state. These payer requirements frequently override standard timeframes and are the primary source of expiration dates for covered treatment.
State regulations also influence how long a physician’s order remains valid, particularly concerning laws surrounding direct access. All states allow patients to receive some treatment from a physical therapist without a physician’s referral, but this access is often limited in time or number of visits. For instance, some state laws allow treatment for up to 30 or 45 days, or a certain number of visits, before a physician’s review and signature are required to continue care.
Finally, the referring healthcare provider can write an explicit expiration date or a “duration of treatment” that supersedes general rules. A physician might specify that the referral is valid for only 60 days, even if the insurance authorization is longer. If the referral specifies a duration, such as “eight weeks of physical therapy,” it is considered complete and expired once that period has passed or the visits are used.
Navigating an Expired or Lapsed Referral
If a physical therapy referral has expired or is about to expire, the most straightforward solution is to contact the original referring physician’s office immediately. The office staff can usually process a request for a new referral or an extension of the existing one. This renewal may require a brief follow-up appointment with the physician to re-evaluate the patient’s condition and determine the medical necessity for continued care.
Patients may also consider “direct access,” which permits seeing a physical therapist without a physician’s referral in all fifty states. This option can bypass the immediate need for a new referral, allowing treatment to continue without interruption. However, even if the state allows direct access, the patient’s insurance plan may still require a physician’s order for treatment to be covered.
The physical therapy clinic staff are often the most knowledgeable resource for navigating lapsed referrals and authorizations. The clinic’s administrative team specializes in verifying referral status, checking insurance authorization limits, and managing the necessary paperwork for renewal requests. They can initiate the process of contacting the referring physician or the insurance company to secure the needed documentation.