Commercial Payer Therapy Visit Limits and Unit Caps: 2026

A therapy claim can get denied for reasons that all look like “prior authorization” from the front desk but resolve very differently on the remittance. Cigna caps physical and occupational therapy at 4 timed codes (one hour) per date of service, and lists a visit that runs past that cap as not covered or reimbursable. Blue Cross Blue Shield of Rhode Island’s Medicare Advantage plans require nothing but notification through visit 14, then prior authorization for every visit after. Carelon’s Rehabilitation Program lets Anthem BCBS Maine commercial members through 12 treatment visits per discipline before it starts reviewing, HealthKeepers Plus Virginia Medicaid members through 8, and Humana routes physical and occupational therapy through Cohere Health with no visit count published on its own list at all.

None of these numbers is interchangeable with another. A visit cap, a timed-code cap, and a notification-only program fail differently when a claim reaches the payer’s system, and the plan-of-care signature rules layered on top differ by discipline within the same payer. This guide pulls the numeric triggers, the policy documents, and the plan-of-care rules directly from each payer’s current published policy, in the same table format as our UnitedHealthcare Medicare Advantage prior authorization post. Current as of September 2026.

The numbers, payer by payer

What do these numeric triggers actually mean?

Every trigger in the table above falls into one of three mechanisms, and each fails differently when a claim reaches the payer.

Visit caps stop paying for an entire visit once a count is reached. BCBSRI’s Medicare Advantage policy authorizes visits 1 through 14 through notification, then requires prior authorization for visits after the 14th. Carelon’s program works the same way at different counts (12 for Anthem BCBS Maine commercial and Anthem BCBS Indiana PT, 8 for HealthKeepers Plus Virginia and Healthy Blue Louisiana): visits below the threshold need no authorization, and every visit after does.

Timed-code or unit caps stop paying for units within a single visit rather than the whole visit. Cigna’s therapy policies cap physical and occupational therapy at “a maximum of 4 timed codes (equivalent to one hour) for each date of service,” and the Not Covered section is direct about what happens past that line: “The treatment visit extends beyond 4 timed unit services per date of service per provider (equivalent to one hour)” is not covered. The limit is measured within a single date of service, regardless of how many visits the member has already had. What the policy does not say is whether Cigna denies only the units past the 4th or the whole visit; the sentence names “the treatment visit” as the non-covered item, so read your own Cigna remittances for how the edit is applied before deciding how to bill a longer session.

Notification-only programs are administrative, not a medical-necessity review. Humana’s own definition draws the line: “‘Notification’ refers to the process by which the physician or other healthcare provider notifies Humana of the intent to provide an item or service.” That process “is distinguished from prior authorization,” and “Humana does not issue an approval or denial for notifications.” BCBSRI’s visits-1-through-14 notification works the same way: it “will administratively authorize” those visits rather than approve them on medical-necessity grounds.

The practical difference shows up at claim submission. A missed prior authorization is a payer’s own stated basis for denial: Carelon’s language is direct, “Failure to contact Carelon for prior authorization of therapy services may result in claim denial.” A visit beyond Cigna’s 4-timed-code cap is, in the policy’s own words, “not covered or reimbursable.” Neither document publishes the specific remittance advice codes a claim will carry, so verify the denial reason codes on your own remittances rather than assuming one standard code applies across payers.

How does Cigna’s four-timed-codes-per-visit rule work?

Cigna’s Medical Coverage Policies for physical therapy (CPG 135) and occupational therapy (CPG 155) use identical language, effective 12/15/2025 with a next review date of 12/15/2026: “A physical therapy treatment session in the outpatient setting lasts up to one-hour on any given day and must be supported in the plan of care and based on a patient’s medical condition. Consistent with Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCDs), up to a maximum of 4 timed codes (equivalent to one hour) will be allowed. PT services in excess of 60 minutes per day are generally not demonstrated to have additional medical benefit in an outpatient setting.” Both policies are branded “Cigna / ASH Medical Coverage Policies,” administered by Cigna Companies.

The cap tracks Medicare’s own timed-unit math. Medicare’s 15-minute unit chart, from the Medicare Claims Processing Manual, Chapter 5, §20.2.C, runs:

Under that chart, Cigna’s cap sits at row 4: 53 to 67 minutes of timed treatment yields 4 units, and a 5th unit needs 68 minutes or more, which the Cigna policy describes as exceeding one hour. See our 8-minute rule explainer for the full minute-to-unit math, including the partial-unit “8-minute rule.” Cigna’s policy itself expresses the cap in timed codes, not minutes, and does not adopt the CMS chart by name, so the number that matters on the claim is the unit count across the timed lines for that date, not the clock.

The wording is narrower than “four services.” It caps “4 timed codes,” and the Not Covered section repeats the same word: the limit applies when “the treatment visit extends beyond 4 timed unit services per date of service per provider.” Medicare’s manual separates “timed” codes, reported in 15-minute units, from “untimed” codes, for which “the provider enters ‘1’ in the field labeled units” regardless of minutes (its example is an evaluation code), per the same Chapter 5, §20.2.B. Cigna’s wording covers timed codes only. That is a reading of what the text says, not a confirmed exemption: the policy does not separately define how Cigna’s claims system counts a “timed code,” so confirm directly with Cigna, or with your clearinghouse’s edits, how an evaluation or supervised-modality code on the same date interacts with the 4-unit cap before assuming it falls outside the count.

How many visits before a payer requires prior authorization?

The visit-count answer depends entirely on the payer, the line of business, and, for Carelon, the state.

BCBS Rhode Island (Medicare Advantage only): notification covers visits 1 through 14 per episode of care, including the initial evaluation, through the plan’s Physical and Occupational Services vendor at evicore.com. Prior authorization is required for every visit after the 14th, reviewed for medical necessity.

Carelon Rehabilitation Program: the threshold varies by health plan and market. Anthem BCBS Maine commercial members go through 12 treatment visits per discipline before prior authorization starts; treatment furnished at the initial evaluation date of service does not count toward that 12. Anthem BCBS Indiana commercial fully insured members get the same 12-visit runway, but only for physical therapy; occupational and speech therapy require authorization starting with the first treatment visit after the evaluation, and Indiana ASO/self-funded members need authorization from the first treatment visit regardless of discipline. HealthKeepers Plus Virginia Medicaid and Healthy Blue Louisiana Medicaid members get through 8 visits per discipline when seen in-network, and unlike Maine, treatment furnished on the initial evaluation date does count toward that 8. Out-of-network providers in Virginia and Louisiana need authorization starting with the first visit.

UnitedHealthcare (Medicare Advantage): the first 6 visits of an initial plan of care are covered without a clinical review, as long as those 6 visits fall within 8 weeks of the first date of service; the plan of care submission covering visit count and duration is still due within 10 business days. See our UHC Medicare Advantage prior authorization guide for the full program.

Humana (Medicare Advantage and D-SNP): the published Prior Authorization and Notification List does not state a visit-count threshold for the PT/OT row at all. Instead, prior authorization applies through Cohere Health, submitted at www.Next.Coherehealth.com, for a specific list of PT/OT codes, with no evaluation or visit-1 exemption stated on the list. Two things our own read of that code list turned up: the PT/OT row includes the re-evaluation codes 97164 and 97168 but not the evaluation codes 97161-97163 or 97165-97167, and we found no speech-language pathology treatment codes (92507, 92508, 92526) anywhere on the list. Treat both as our search of the September 1, 2026 revision, not a Humana statement, and confirm in the Cohere portal. One exception softens that for new patients: “Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member’s enrollment for active courses of treatment that started prior to enrollment,” though Humana “may review the services furnished during that active course of treatment against permissible coverage criteria when determining payment.”

Who has to sign the plan of care?

Signature requirements differ by payer and, within Aetna, by discipline.

Cigna (PT and OT): both CPG 135 and CPG 155 require the plan of care to be established by the treating therapist, and the required elements list ends with the therapist’s signature, “Signature of the patient’s physical therapist” (PT) or “Signatures of the patient’s occupational therapist” (OT). Progress reports separately require “Signature and title of qualified professional responsible for the therapy services.” Neither policy requires a physician signature on the plan of care itself.

Aetna PT (CPB 0325): the documentation appendix ends the same way, with “Signature of the patient’s physical therapist,” and the policy states only that “PT must be provided in accordance with an ongoing, written plan of care.” Nothing in CPB 0325 requires physician review or approval of that plan.

Aetna OT (CPB 0250): the plan of care “must be signed by the member’s occupational therapist,” but the policy adds a physician-review requirement the PT bulletin does not carry: “OT must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations.” The medical-necessity criteria begin the same way OT is covered, “when this care is prescribed by a physician.” CPB 0250’s last review date is 05/19/2026.

That asymmetry, Aetna requiring physician review for OT plans of care but not PT plans of care, sits entirely in the current published text as of each bulletin’s last review date; neither bulletin describes a recent change to this requirement.

None of the four commercial policies above adopt Medicare’s certification and recertification timelines. For how Medicare’s plan-of-care certification and recertification rules work, see our plan of care certification guide.

How do you verify a patient’s therapy benefit before visit one?

Work through the same steps before the first visit, and again at each numeric trigger in the table above:

What do you do when a payer’s cap contradicts the plan of care?

Cigna’s cap is written per date of service and per provider, so a plan of care that calls for more than four timed units in a session leaves a practice two ways to reconcile the two documents, and the policy itself endorses neither. One is to bill only the four timed units the policy allows for that date and treat anything beyond them as furnished but not billable to Cigna. The other is to spread the plan’s minutes across more dates of service so that no single date exceeds the cap. Either way, the treatment note still has to reflect what was actually furnished: CPG 135 requires each treatment session record to include “Specific treatment(s) provided that match the procedure codes billed” and “Total treatment time,” so a note that shows 75 minutes of timed treatment against four billed units needs to make the difference legible rather than hide it. The policy also expects the plan of care to justify the session length in the first place (“must be supported in the plan of care and based on a patient’s medical condition”), which is the argument to make in an appeal if the clinical picture genuinely needs more than an hour.

Whatever agreement you use to bill the patient for services a commercial or Medicare Advantage payer won’t cover, it is not an ABN. The Advance Beneficiary Notice of Noncoverage is a Medicare fee-for-service instrument: CMS is explicit that “The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied.” Commercial and Medicare Advantage plans run on the participation agreement instead. BCBSRI’s own policy states the standard plainly: “If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions.” For how the ABN itself works under Original Medicare, see our ABN and modifiers guide.

How often do these policies change?

Every row in the table above carries its own review cycle, and they don’t sit on the same calendar:

• Cigna CPG 135 and CPG 155 (four timed codes): next review 12/15/2026
• Cigna Policy 0600 (site of care): next review 7/15/2027
• Aetna CPB 0325 (PT): next review 03/25/2027
• Aetna CPB 0250 (OT): next review 03/11/2027
• BCBSRI Medicare Advantage policy: last reviewed 08/05/2026, republished in Provider Update November 2026
• Humana Medicare Advantage and D-SNP list: effective 07/01/2026, revised 09/01/2026, and Humana revises this list mid-cycle
• Carelon Rehabilitation Program FAQ: updated 7/21/2026

Re-verify each payer’s numeric trigger and policy document quarterly rather than relying on this table indefinitely. A next-review date is when a payer is scheduled to revisit a policy, not a guarantee it won’t change sooner, as Humana’s mid-cycle revision shows.

Cigna’s 4-timed-code cap is a hard ceiling set at the payer, but nothing stops a practice from setting its own ceiling earlier, at the point of documentation. PrismEHR lets organizations define their own billing rules, including minute and unit restrictions by payer, enforced as the note is written and reinforced again at claim creation, so a 5th timed unit gets flagged before the claim is ever built. See how it fits physical therapy practices, and see our 8-minute rule guide for how the minute-to-unit math behind that cap works.