RE: All Personalized Recovery Oriented Services (PROS) Providers
IMPACTED PLANS: MEDICAID, HIV SNP, HARP, and MAP
In July 2024, NYS submitted the proposed State Plan Amendment (SPA) #23-0098 to the Center for Medicaid and Medicare Services (CMS) to implement a Personalized Recovery Oriented Services (PROS) program redesign which would also result in billing and reimbursement changes.
OMH released notification that the PROS Redesign: Billing and Reimbursement Changes were approved and will be implemented Effective April 1, 2025. MetroPlusHealth is required to complete all necessary system edits and configure our system to ensure all payable claims for OMH PROS programs and applicable dates of service are reimbursed on or after April 1, 2025.
The new PROS model will eliminate the concept of program participation time and reduce the number of monthly base rates from five (5) to three (3) tiers. The existing rate codes 4520 – 4524 will be replaced by new rate codes 4516 – 4518 as outlined below.
Rate Code Changes for Providers:
Table 1: Updated PROS Monthly Base Rate Coding Taxonomy
| Rate Code Service Title | Rate Code | Procedure Code | Modifiers | Units of Service |
|---|---|---|---|---|
| PROS Monthly Base Rate – Tier 1 | 4516 | H2019 | U1 | 4 – 11 |
| PROS Monthly Base Rate – Tier 2 | 4517 | H2019 | U2 | 12 – 43 |
| PROS Monthly Base Rate – Tier 3 | 4518 | H2019 | U3 | 44+ |
* PROS billing codes remain unchanged for all other services outside of the Community Rehabilitation and Support (CRS) component.
Billing Changes for Providers: Redefining the PROS unit & eliminating the concept of program participation time
- One unit will be defined as 15 continuous minutes of service provided to an individual or collateral, or 30 continuous minutes of service provided to an individual or collateral in a group setting.
- The monthly base rate is determined by adding up all PROS units for CRS, Intensive Rehabilitation (IR), Ongoing Rehabilitation and Support (ORS), and Clinical Treatment (CT) services that are used during the month. It is important that this base rate includes at least 4 CRS units. (see #4 below)
- For calculating units, off-site services offered for the same duration will count as two units instead of one. This rule applies to both CRS and add-on components.
- For ex: If a member receives 45 minutes of off-site PROS CRS, it will count as 6 units instead of 3 for base rate calculations. Similarly, 60 minutes of off-site group services will be counted as 4 units rather than 2. For PROS programs, “off-site” refers to any appropriate community location that is not a licensed PROS site. This does not include spaces that share the same address as a PROS program.
- To bill for the PROS monthly base rate, at least 4 units of CRS services must be provided each month. These services can be delivered either on-site or off-site. Each member’s service should last at least 60 minutes, while group services need a minimum of 120 minutes throughout the month. When checking if the PROS program meets the duration requirements for billing the IR add-on, off-site services do not count as double the units.
- To bill for the IR add-on component, a minimum of 6 service units must be delivered in a month, including at least one IR service. These services can take place either on-site or off-site and must be at least 90 minutes for individual services and 180 minutes for group services for the month. When checking if the PROS program has met the time requirement for billing the IR add-on, off-site services are not counted as double.
- A maximum of five units may be accumulated a day for services delivered onsite. For off-site services, the daily maximum is 10 units, which equals 75 minutes of one-to-one services or 150 minutes of group-based services.
- PROS providers must report the actual number of units on their claim, to support the State’s monitoring of service utilization within the monthly base rate.
MetroPlusHealth will ensure that all applicable policies and procedures are updated and provider relations and billing/claiming staff are trained on the new PROS rate codes and billing changes to ensure they can assist providers as needed, update and amend contracts with PROS providers (if applicable), offer claims testing to PROS providers to ensure claims will be processed and paid appropriately, and technical assistance as needed.
For More Information and Guidance for PROS Providers: (refer to the links below)
- PROS Redesign Billing and Reimbursement Changes
- PROS OMH Page
- PROS Redesign: Billing Training for Providers
- PROS Redesign: Billing Training for MCOs
Please note: MMCPs and Providers may need to create an account with MCTAC to access this webinar. There is no charge to have an account with MCTAC and providers can access many useful trainings and resources through the MCTAC site.
If you have any questions regarding this memo or you are a PROS provider who is interested in conducting claims testing with MetroPlusHealth prior to the April 1, 2025 effective date, please contact MetroPlusHealth at: [email protected].