Maryland - Physical Therapy Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Maryland, Physical Therapy (PT) services under Medicaid and Home and Community-Based Services (HCBS) waivers provide essential evaluation and treatment to address mobility, strength, balance, and fall risk. These services are delivered either through the Medicaid State Plan for acute and restorative needs or as extended services under waivers like the Community Options (CO) Waiver and Community Pathways Waiver to help beneficiaries maintain independence in their homes and communities.

The single biggest structural barrier to entry depends on the provider's business model. For independent practitioners, the absolute prerequisite is holding an active, unrestricted license from the Maryland Board of Physical Therapy Examiners before any Medicaid enrollment can begin. For agencies intending to hire PTs to deliver services in a beneficiary's home, the primary structural barrier is obtaining a Residential Service Agency (RSA) license from the Maryland Office of Health Care Quality (OHCQ). If the agency intends to operate as a Medicare-certified Home Health Agency (HHA), it faces a strict Certificate of Need (CON) requirement from the Maryland Health Care Commission (MHCC), which acts as a hard cap on new market entrants.

1. Service Definition and Scope

Maryland Medicaid defines Physical Therapy as skilled services provided by or under the direction of a licensed physical therapist. These services include evaluations, therapeutic exercises, gait training, and modalities designed to restore function, improve mobility, relieve pain, or prevent physical decline.

Under HCBS waivers, PT services often supplement State Plan benefits. While State Plan PT typically requires a restorative goal, waiver-funded PT may focus on safe maintenance programs, caregiver training, and environmental adaptations to prevent institutionalization.

• Covered Modalities: Therapeutic exercise, neuromuscular reeducation, gait training, manual therapy, and wheelchair management.
• Target Population: Medicaid beneficiaries experiencing functional decline, high fall risk, or recovering from acute injury, surgery, or neurological events.
• Service Settings: Beneficiary homes, community settings, Medical Day Care centers, or outpatient clinics.
• Exclusions: Services that can be safely performed by non-skilled personnel (such as routine walking programs) or maintenance therapy lacking a skilled rehabilitative or safe-maintenance goal are typically not covered.
• Supervision: Physical Therapist Assistants (PTAs) may provide treatments but must be supervised by a licensed PT who performs the initial evaluation and establishes the Plan of Care.

2. Regulatory and Oversight Agencies

Physical therapy providers in Maryland are regulated by a combination of professional licensing boards, facility regulators, and the state Medicaid agency. The Maryland Department of Health (MDH) serves as the umbrella agency overseeing Medicaid enrollment and HCBS waiver administration.

Facility and agency licensure is handled separately from individual professional licensure, meaning a group practice or home care agency must satisfy multiple regulatory bodies before billing Medicaid.

• Maryland Department of Health (MDH): Administers the Medical Assistance Program, manages the ePREP enrollment portal, and oversees HCBS waivers.
• Office of Health Care Quality (OHCQ): The MDH division responsible for inspecting and licensing Residential Service Agencies (RSAs) and Home Health Agencies (HHAs) that deliver in-home PT.
• Maryland Board of Physical Therapy Examiners: Issues and regulates individual PT and PTA licenses under the Code of Maryland Regulations (COMAR) Title 10, Subtitle 38.
• Maryland Health Care Commission (MHCC): Regulates the Certificate of Need (CON) process, which is required for establishing new Medicare-certified Home Health Agencies.
• Developmental Disabilities Administration (DDA): Oversees providers delivering PT under the Community Pathways Waiver, requiring separate DDA provider approval.

3. Gatekeeping Prerequisites: Who Can Even Apply

Maryland enforces strict structural preconditions before a Medicaid provider application is accepted. An applicant cannot simply apply to be a Medicaid PT provider without first securing the underlying legal and professional authority to operate in the state.

For agencies, the type of licensure dictates the barriers. RSAs do not require a Certificate of Need but must pass OHCQ licensure. HHAs require a CON, which is highly restricted. Individual practitioners must be fully licensed and registered with state tax authorities.

• Individual Licensure: An active, unrestricted license from the Maryland Board of Physical Therapy Examiners is a hard prerequisite for individual enrollment.
• Agency Licensure (RSA): Agencies providing in-home PT must obtain an OHCQ Residential Service Agency license before initiating Medicaid enrollment.
• Certificate of Need (CON): Required from MHCC only if establishing a new Medicare-certified Home Health Agency; RSAs are exempt from CON review.
• Business Registration: Entities must be in good standing with the Maryland State Department of Assessments and Taxation (SDAT). Individual billing providers must have an "L" prefix on their SDAT ID.
• NPI Requirement: Applicants must hold an active Type 1 NPI (for individuals) or Type 2 NPI (for groups/agencies) with a taxonomy code that exactly matches the requested Medicaid provider type.
• Tax Documentation: A signed IRS Form W-9 and an official IRS 147C letter matching the SDAT legal name are required to pass the ePREP screening.

4. Licensure and Certification Requirements

Obtaining the necessary licenses requires demonstrating clinical competency, operational readiness, and adherence to Maryland's health and safety codes. Individual PTs must meet national educational standards and pass state-specific exams.

Agencies applying for an RSA license through OHCQ must submit comprehensive operational policies, designate qualified administrative and clinical leadership, and pass an initial site inspection.

• Educational Standard: Graduation from a physical therapy program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE).
• Examination: Passing scores on the National Physical Therapy Examination (NPTE) and the Maryland Jurisprudence Exam.
• RSA Application (Agencies): Submission of operational procedures, a nurse or administrator resume, sample clinical forms, and patient rights policies to OHCQ.
• Continuing Education: Individual PTs must complete 30 Continuing Education Units (CEUs) every two years to maintain Maryland Board licensure.
• Liability Insurance: Proof of professional liability coverage showing the policy number and active coverage dates is required for both individuals and agencies.
• CPR Certification: All patient-facing clinical staff must maintain active Basic Life Support (BLS) or CPR certification.

5. Medicaid Provider Enrollment

Maryland Medicaid enrollment is conducted entirely online through the electronic Provider Revalidation and Enrollment Portal (ePREP). Note that MDH will transition from ePREP to the Maryland Provider Registration and Information Management Enterprise (MPRIME) portal in October 2026.

Providers must enroll under the appropriate Provider Type (e.g., Provider Type 34 for Physical Therapists). Enrollment with the state Medicaid agency is required even if the provider intends to exclusively serve managed care (HealthChoice) patients.

• Enrollment Portal: Applications must be submitted via ePREP (transitioning to MPRIME in Oct 2026).
• Provider Agreement: Mandatory electronic signature of the MDH Provider Agreement and specific PT addenda within the ePREP system.
• Application Fee: Institutional providers (like HHAs) are subject to the federal Medicaid/Medicare application fee (approx. $709); individual PTs and PT groups are generally exempt.
• Rendering Provider Affiliation: Group practices must link their individually licensed rendering PTs to the group's Type 2 NPI within ePREP.
• MCO Credentialing: After state enrollment, providers must separately credential and contract with HealthChoice Managed Care Organizations (e.g., MedStar Family Choice, Aetna Better Health) to treat managed care populations.
• Revalidation: Maryland requires providers to revalidate their Medicaid enrollment through ePREP every five years.

6. Staffing, Training and Background Checks

Maryland mandates rigorous background screening and credential verification to protect vulnerable Medicaid populations. Agencies must maintain pristine personnel files subject to OHCQ and MDH audits.

Supervision rules for Physical Therapist Assistants (PTAs) and unlicensed aides are strictly enforced under COMAR, dictating exactly what tasks can be delegated and billed.

• Criminal Background Check (CJIS): Fingerprint-based state and FBI background checks are required via the Maryland Department of Public Safety and Correctional Services.
• PTA Supervision: PTAs must work under the direction of a Maryland-licensed PT, who must perform the initial evaluation and be available for consultation (COMAR 10.38.03).
• OIG Exclusion Verification: Providers must conduct monthly screenings of all staff against the federal LEIE and the Maryland Medicaid exclusion lists.
• Aide Restrictions: Unlicensed physical therapy aides may only perform non-billable, routine tasks and cannot provide skilled interventions.
• Mandatory Reporting Training: Staff must be trained on Maryland laws regarding the mandatory reporting of abuse, neglect, and exploitation of vulnerable adults and children.

7. Documentation, Policies and Records

Clinical documentation must clearly establish medical necessity and demonstrate that the services require the skills of a licensed therapist. For HCBS waiver participants, PT services must also integrate with the broader care plan.

Incomplete or delayed documentation, particularly missing physician signatures on Plans of Care, is a primary driver of audit failures and clawbacks in Maryland.

• Initial Evaluation: Must include a comprehensive assessment documenting baseline mobility, strength, balance, and standardized fall risk metrics (e.g., Timed Up and Go test).
• Plan of Care (POC): Must detail specific, measurable goals, frequency, and duration, and must be signed by the referring physician or authorized practitioner within 30 days.
• Progress Notes: Required for every session, detailing the specific interventions provided, the patient's response, and progress toward POC goals.
• Waiver Integration: For HCBS participants, PT goals must align with and be documented in the LTSSMaryland Person-Centered Service Plan (PCSP).
• Record Retention: Maryland Medicaid requires providers to retain all medical and financial records for a minimum of 6 years from the date of service.
• Discharge Summary: Must be completed when goals are met or services are no longer medically necessary, detailing final functional status.

8. Billing, Rates and Claims

Billing pathways in Maryland depend on the patient's enrollment status. Fee-for-Service (FFS) claims are submitted directly to the state, while managed care claims go to the respective MCOs. HCBS waiver claims are often processed through the LTSSMaryland system.

Providers must verify eligibility on the exact date of service, as Maryland Medicaid coverage can shift between FFS and MCOs month-to-month.

• Billing Systems: eMedicaid portal for FFS claims; LTSSMaryland for specific waiver claims; Availity or MCO-specific clearinghouses for HealthChoice claims.
• Coding: Standard CPT codes are used (e.g., 97110 Therapeutic Exercise, 97116 Gait Training, 97161-97163 PT Evaluations).
• Eligibility Verification: Must verify active coverage and MCO assignment via the Eligibility Verification System (EVS) on the date of service.
• Prior Authorization: MCOs typically require prior authorization for PT services; FFS Medicaid may allow an initial cap of unmanaged visits before requiring authorization.
• Reimbursement Rates: FFS rates are dictated by the MDH Medical Care Programs fee schedule, updated annually (typically ranging from $60-$85 per evaluation, depending on complexity).
• Third-Party Liability (TPL): Medicaid is the payer of last resort; providers must bill Medicare or commercial insurance first and submit the Explanation of Benefits (EOB) with the Medicaid claim.

9. Approval Sequence and Timeline

The approval process is strictly sequential. A provider cannot apply for Medicaid enrollment without a license, and cannot credential with an MCO without a Medicaid Provider ID.

Delays often occur at the OHCQ licensure stage for agencies or during the ePREP review if tax documents do not perfectly match state records.

• Step 1 (Individuals): Obtain Maryland Board of Physical Therapy Examiners license (typically 4-8 weeks).
• Step 1 (Agencies): Obtain OHCQ RSA license, which includes policy review and an initial site inspection (typically 3-6 months).
• Step 2: Register the business with SDAT and obtain an official IRS 147C letter (1-3 weeks).
• Step 3: Submit the ePREP application and sign the MDH Provider Agreement (30-90 days for state review and approval).
• Step 4: Register for eMedicaid portal access once the Medicaid Provider ID is issued (1 week).
• Step 5: Apply for credentialing and contracting with HealthChoice MCOs (90-120 days).

10. Common Denials and Survey Findings

Applications and claims are frequently rejected for administrative mismatches rather than clinical issues. ePREP is highly sensitive to data discrepancies between federal, state, and application records.

During OHCQ surveys or MDH audits, documentation gaps are the most common source of citations and financial recoupments.

• Taxonomy Mismatch: ePREP applications are immediately returned if the NPI taxonomy in NPPES does not exactly match the requested Medicaid provider type.
• Name Discrepancies: Enrollment denials occur when the legal business name on the W-9 does not perfectly match the IRS 147C letter or SDAT record.
• Capitation Denials: Claims deny when a provider bills FFS Medicaid for a patient who was actively enrolled in a HealthChoice MCO on the date of service.
• Missing Signatures: OHCQ citations and MDH clawbacks frequently result from Plans of Care lacking timely physician signatures (within 30 days).
• Unlicensed Personnel: Citations for using physical therapy aides to perform billable skilled interventions, violating COMAR regulations.
• Location Errors: Claims deny if the service location address on the claim does not match the exact address enrolled and approved in ePREP.

11. Key Contacts and Resources

Providers must maintain active communication with several state entities to ensure compliance and resolve enrollment or billing issues.

Utilizing the correct portal and contacting the appropriate helpdesk is critical for timely issue resolution.

• ePREP Hotline: 1-844-463-7768 (Monday-Friday, 9:00 a.m. to 5:00 p.m.) for Medicaid enrollment status and portal support.
• Maryland Board of Physical Therapy Examiners: (410) 764-4718 for individual licensure inquiries and renewals.
• OHCQ RSA Unit: Oversees agency licensing for in-home care providers; contact via the MDH OHCQ directory.
• MDH Provider Enrollment Webpage: health.maryland.gov/mmcp/provider for transmittals, ePREP addenda, and MPRIME transition updates.
• Eligibility Verification System (EVS): Accessed via the eMedicaid portal to confirm patient coverage status and MCO assignment.
• LTSSMaryland Help Desk: For technical support related to HCBS waiver billing and Person-Centered Service Plan integration.

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