Robert Hall

Hiring a physical therapist should expand a practice’s capacity to serve patients. Too often, it instead begins a months-long administrative limbo. A payer may acknowledge an application late, identify missing information piecemeal, approve the clinician without correctly loading the clinician into its claims system, or delay linking the clinician to the practice’s locations. The predictable results are held or denied claims, avoidable rework, disrupted cash flow, and delayed access to care.

APTA Private Practice, in collaboration with APTA State Affairs, has developed a model provider credentialing and enrollment bill to help state chapters address this problem. The proposal does not require a health plan to credential every applicant. It requires a fair, transparent, and enforceable process—and makes clear that credentialing is not finished if the payer’s systems still cannot recognize the provider or pay a clean claim correctly.

What the model legislation would do

The model bill establishes a sequence of defined responsibilities rather than allowing an application to disappear into an open-ended payer workflow. Its central protections include:

  • Prompt confirmation of receipt. The payer must acknowledge the application within seven calendar days and provide contact information for the person reviewing it.
  • A defined completeness review. If information is missing, the payer must identify the deficiencies in writing or electronically within 30 calendar days, rather than raising new requirements indefinitely.
  • A firm decision deadline. The payer must conclude credentialing within 60 calendar days. The clock pauses while the provider resolves a documented deficiency and resumes when the completed material is returned.
  • Retrospective payment protection. If the provider is ultimately credentialed and a fully executed participating-provider contract was in effect before the services were delivered, covered reimbursable services are payable back to the date the payer received the completed application, unless federal law preempts that result.
  • Operational completion. The payer remains responsible for fully loading the provider into its claims system and updating its provider directory. An approval letter is not enough if claims still deny as out of network or the public directory remains wrong.
  • Uniformity and enforcement. The model directs the state’s insurance regulator to establish a uniform application and places enforcement with the regulator.

Why the details matter

A statutory deadline is only useful if the law identifies when the clock begins, what pauses it, and what happens if the payer misses it. The model therefore defines key terms—including applicant, application, completed application, credentialing, participating provider, and fully credentialed—and requires written or electronic notices at the points where disputes most often arise.

The distinction between credentialing and enrollment is especially important. Credentialing evaluates whether a clinician satisfies network participation standards. Contracting establishes the legal relationship and payment terms. Enrollment and system loading connect the approved clinician to the group, locations, billing identifiers, claims edits, and directory. A reform that addresses only the credentialing decision can leave practices with the same payment problem under a different name.

States already provide workable examples

Wyoming’s 2025 law sponsored by State Rep. Ken Clouston, PT and supported by APTA Wyoming provides a broad precedent for health care providers. It requires a receipt within seven days, an incompleteness notice within 30 days, completion of credentialing within 60 days, and—when its conditions are satisfied—reimbursement back to receipt of the completed application. The law applies to applications submitted on or after July 1, 2025. Wyoming House Bill 82

Colorado also demonstrates the value of enforceable timelines, although its existing 2021 statute is narrower because it applies to physicians. It requires acknowledgment within seven days and completion within 60 days after receipt of a completed application. Colorado Senate Bill 21-126

Each state must tailor the covered provider classes, plans, enforcement authority, remedies, effective date, recredentialing rules, and interaction with existing prompt-payment and network-adequacy laws. State insurance laws also generally reach state-regulated insurance products, not self-funded employer plans governed primarily by ERISA, and federal program requirements may preempt particular provisions.

A practical agenda for state advocates

Before introducing legislation, chapters may wish to consider collecting specific examples: submission and approval dates, repeated requests for the same information, days from approval to successful claim payment, directory errors, claims held or denied, staff hours spent correcting payer records, and patients whose care was delayed. Those facts turn an administrative complaint into an access-to-care and market-function problem ripe for regulatory reaction.

The Wyoming and Colorado laws should be treated as starting points along with the APTA state model bills available as the first item uploaded in the Library of the SPARC Forum in the APTA Community. Do not copy these or other bills without review. It is also important to note that State Chapters are recommended as advocacy leads for the physical therapy profession and define the priorities for the Chapter’s advocacy in each state. Chapters leading the way is critical, as legislators and regulators should hear one unified voice from the physical therapy profession. In advocacy, there is always strength in numbers, but weakness in division.

The coalition should also extend beyond physical therapy. Physicians, behavioral health clinicians, other rehabilitation providers, hospitals, independent practices, and health care workforce groups encounter the same failures. A broader coalition can demonstrate that the bill is not seeking a special exception; it is establishing a basic operating standard for payer networks.

The strongest bill will also resist a common compromise: a deadline without a remedy. If a payer can miss the deadline without consequence, delay remains the rational business choice. Advocates should press for regulatory jurisdiction, complaint rights, meaningful corrective action, retrospective payment where appropriate, and clear responsibility for claims-system and directory accuracy.

The bottom line

Credentialing should protect patients and verify professional qualifications. It should not function as an interest-free loan from practices to insurers or an administrative barrier that keeps qualified physical therapists from serving patients. The APTA Private Practice model gives state chapters a disciplined framework for converting that principle into enforceable law.

For the model language and assistance adapting it to your state under your Chapter’s leadership, contact Bob Hall at rhall@ppsapta.org or reference the upload of the resource on the SPARC Forum on the APTA Community. APTA State Affairs also provides legislative support, grassroots advocacy, and resources to APTA state chapters pursuing state legislation to improve payment and reduce administrative burden.

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