Here at WebPT, we’re looking to keep you up-to-date on the latest updates from both commercial insurance companies and the Center for Medicare and Medicaid Services (CMS) so that you can stay compliant and avoid those unnecessary delays and headaches that add hours to your already long days. Currently, there are a couple of shifts within the Medicaid program and at UnitedHealthcare (UHC) that could impact your practice.  

Gainwell Technologies and The Impact on Claims Processing

Over the past year, CMS has transitioned multiple Medicaid programs to the Gainwell Technologies Payor Portal in an effort to centralize claims integration, provider contracting, financial management, and member benefits. However, this transition has introduced new challenges—such as updated claim edits and verification requirements that differ from prior processes.

One major change affecting providers is the verification process for credentialing and contract mapping. Depending on the state Medicaid program, Gainwell now pulls provider data directly from the National Plan and Provider Enumeration System (NPPES) registry, either nightly or weekly.

Why NPPES Data Matters

So, why does this matter for you and your practice? As we’ve seen here at WebPT, if your NPPES information is incomplete or outdated, claims may not be mapped correctly—leading to:

• Credentialing issues
• Incorrect reimbursement rates
• Payment delays

Across the industry, one of the leading causes of delays in claims processing has been outdated information in the NPPES registry. Missing servicing locations or incorrect taxonomy codes are directly impacting claims processing and payment accuracy.

What’s causing the problems? 

• Outdated group billing NPI data: Most delays have been tied to missing or incorrect information at the group level.
  
• Servicing location errors: If only the billing address is listed, Medicaid may apply the wrong contract pricing.
  
• Contract mapping mismatches: When Gainwell cannot properly link providers to their correct group contracts, claims may be held until information is corrected—resulting in revenue delays.
  

While individual rendering provider NPI data has not frequently caused delays, errors still arise when Medicaid programs attempt to connect providers with the right contracts.

Best Practices for Physical Therapy Providers

To avoid claim delays and reimbursement discrepancies, physical therapy practices should:

• Review and update NPPES records regularly.
  
• Ensure mailing addresses, servicing locations, and taxonomy codes are complete and accurate.
  
• Confirm both group and individual provider information is current.
  

Keeping this information accurate allows Gainwell Technologies to properly map contracts and apply the correct reimbursement rates. There have been several instances where Medicaid applied incorrect contract pricing because the NPPES registry listed only the billing address, not the servicing location. Claims were reimbursed incorrectly until the error was resolved, causing avoidable payment disruption.

Take Action

Ensuring your NPPES information is accurate and up to date is the best way to prevent future claims delays and revenue issues. If you’re looking for more information, be sure to check out the NPPES Registry, NPPES Search, or the NPI Help Page.

Policy Updates from UnitedHealthcare

UHC has also announced a series of changes set to take effect on November 1, 2025, specific to their Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) services. 

• Under their guidelines for Coverage Rationale, UHC has clarified that services: 
  
  • Must not duplicate other therapy services provided at the same time (e.g., speech, physical, occupational), and
  • Must provide distinct treatment goals, plans, and therapeutic modalities.
• As part of Speech and Language Considerations, details have been added to the policy:
  
  • Bilingual/multilingual speakers: may be misclassified as developmentally delayed; proficiency in both languages should not automatically be expected.
  • Limited English proficiency: requires culturally and linguistically appropriate, norm-referenced standardized testing across all languages the child is exposed to.
  • Criteria for therapy with limited English proficiency – all must be met:
    
    • Speech deficits appear in the language of highest proficiency.
    • Language deficits appear in the language of highest proficiency.
    • Services must be delivered in the language of highest proficiency.
      
  • Dyslexia: test results confirming a diagnosis of expressive/receptive language delay must be included with therapy goals addressing those deficits (per ASHA guidance).

As we see additional important changes coming from payers, we’ll be sure to share those out with rehab therapists—so pay attention ot this space!