Waiver Consulting Group — Start any program. In any state.

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

Last reviewed: 2026-09-10

The Vermont Secretary of State’s Office of Professional Regulation (OPR) licenses Physical Therapists under 26 V.S.A. Chapter 38, while the Department of Disabilities, Aging and Independent Living (DAIL) Adult Services Division (ASD) must approve providers before they can bill for waiver-funded physical therapy. Physical therapy services in Vermont address mobility, strength, balance, and fall risk for Medicaid beneficiaries, including those enrolled in the Choices for Care (CFC) and Traumatic Brain Injury (TBI) programs.

To operate as a Medicaid waiver provider, a physical therapist must first secure an active OPR license and then submit a provider enrollment application directly to DAIL ASD. Only after DAIL ASD issues an approval letter may the provider submit a Medicaid enrollment application through the Gainwell Technologies Provider Management Module (PMM) to receive a Vermont Medicaid provider ID.

1. Service Definition and Scope

In Vermont, physical therapy services include the evaluation, diagnosis, prognosis, and treatment interventions designed to improve mobility, strength, and balance while reducing fall risk. Under Vermont Medicaid and HCBS waivers, these services must be medically necessary and ordered by a physician or authorized practitioner.

The scope of practice is defined by 26 V.S.A. Chapter 38, which mandates that physical therapists communicate the status of a patient’s progress to the referring health care professional. Services may be delivered in clinical settings, the member's home, or community-based settings depending on the specific waiver authorization.

2. Regulatory and Oversight Agencies

Physical therapy licensure is managed by the Office of Professional Regulation (OPR) under the Vermont Secretary of State. OPR handles initial applications, exams, and license renewals.

For Medicaid and waiver participation, the Department of Disabilities, Aging and Independent Living (DAIL) Adult Services Division (ASD) oversees waiver provider approvals, while the Department of Vermont Health Access (DVHA) and its fiscal agent, Gainwell Technologies, manage the Medicaid enrollment and claims processing.

3. Gatekeeping Prerequisites: Who Can Even Apply

Vermont imposes a strict sequential approval process for physical therapists seeking to provide services under the Choices for Care (CFC) or Traumatic Brain Injury (TBI) waivers. An applicant cannot simply enroll in Medicaid; they must first submit a specific enrollment application to the DAIL Adult Services Division (ASD).

Gainwell Technologies will reject any Medicaid enrollment application for waiver-specific physical therapy taxonomy codes if the applicant does not include the official DAIL ASD approval letter. Furthermore, the applicant must hold an active, unencumbered Vermont PT license or a valid Physical Therapy Licensure Compact privilege before DAIL will review the application.

4. Licensure and Certification Requirements

To obtain a physical therapist license in Vermont, applicants must graduate from a professional physical therapy education program accredited by a national accreditation agency approved by the OPR Director. Applicants must also pass the National Physical Therapy Examination (NPTE).

Foreign-educated applicants must undergo a credentials evaluation to demonstrate their education is substantially equivalent to US standards and pass an approved English proficiency exam if their native language is not English. Vermont also participates in the Physical Therapy Licensure Compact, allowing eligible out-of-state PTs to purchase a compact privilege to practice.

5. Medicaid Provider Enrollment

Once licensed by OPR and approved by DAIL ASD (if applicable), physical therapists must enroll in Vermont Medicaid using the online Provider Management Module (PMM) managed by Gainwell Technologies. Paper applications are no longer accepted.

Enrollment requires submitting a signed General Provider Agreement, a copy of the OPR license, and completing federal screening requirements under Section 6401 of the Affordable Care Act (ACA). A Vermont Medicaid provider ID number is issued upon acceptance, and payments cannot be made until this number is assigned.

6. Staffing, Training and Background Checks

Physical therapists operating independently or within an agency must comply with Vermont's background check requirements to ensure the safety of vulnerable adults receiving HCBS. This includes checks against the Vermont Adult Abuse Registry and the Vermont Crime Information Center (VCIC).

Agencies employing physical therapist assistants (PTAs) must ensure that PTAs are properly licensed and operate under the direct supervision of a licensed PT. All staff must maintain current CPR certification and complete mandated reporter training for adult abuse and neglect.

7. Documentation, Policies and Records

Vermont Medicaid requires physical therapists to maintain comprehensive clinical and financial records that justify the medical necessity and delivery of billed services. Documentation must align with commonly accepted standards of professional practice and Vermont Medicaid's General Provider Manual.

Records must include the referring physician's order, initial evaluation, individualized treatment plan, daily progress notes, and discharge summary. Providers must retain these records for a minimum of seven years and make them available for audit by DVHA or Gainwell upon request.

8. Billing, Rates and Claims

Physical therapy services are billed to Vermont Medicaid using the CMS-1500 claim form or its electronic equivalent (837P). The billing provider's NPI must be entered in field 33 of the CMS-1500 form, and the name must exactly match the format enrolled with Vermont Medicaid.

Providers must accept Vermont Medicaid's payment as payment in full and are strictly prohibited from balance billing members for any remaining amounts. Claims must be submitted within Vermont Medicaid's timely filing limits, typically 180 days from the date of service.

9. Approval Sequence and Timeline

The approval sequence begins with obtaining a physical therapy license from the Vermont OPR, which typically takes 2 to 4 weeks once all transcripts and exam scores are received. Following licensure, providers seeking to serve waiver participants must apply to DAIL ASD.

DAIL ASD review can take 30 to 60 days. Once the DAIL approval letter is secured, the provider submits the Medicaid enrollment application via the Gainwell PMM. Gainwell's processing time for a complete application is generally 30 to 45 days, culminating in the issuance of a Medicaid Provider ID.

10. Common Denials and Survey Findings

A frequent cause for Medicaid enrollment denial is the failure to obtain and attach the required DAIL ASD approval letter before submitting the application to Gainwell for waiver-specific services. Applications are also routinely delayed if the provider's name on the application does not perfectly match the name registered with the IRS and OPR.

During audits, DVHA commonly recoups funds when physical therapists fail to document the communication of the patient's progress to the referring physician, as required by 26 V.S.A. Chapter 38, or when daily treatment notes lack specific details regarding the interventions performed and the time spent.

11. Key Contacts and Resources

Providers should utilize the official state portals for the most current manuals, fee schedules, and application forms. The Gainwell Provider Enrollment Unit is the primary contact for questions regarding the Provider Management Module and Medicaid ID issuance.

For questions regarding waiver program rules and DAIL approval, providers should contact the Adult Services Division directly. Licensure inquiries should be directed to the Office of Professional Regulation.

See all Vermont services · Vermont Medicaid consulting · book a consultation.