RE: PROS Billing & Claiming Manual Update

IMPACTED PLANS: MEDICAID, HIV SNP, HARP, and MAP

OMH has released an updated PROS Billing and Claiming Manual to clarify billing and reimbursement expectations for the PROS redesign, which were effective as of April 1, 2025.

The following changes are specific to reimbursement for Clinical Treatment (CT) add-ons during pre-admission:

1. Page 9: Registration Process at Admission
   1. PROS admission begins when the program enters a registration request on the CAIRS PROS Admission screen.
   2. Until that registration is processed, the PROS provider will not be reimbursed for any services other than pre-admission (and the Clinical Treatment add-on component, if applicable) for the member.
   3. Providers must submit registrations and all other reporting documents required for all members (non-Medicaid and Medicaid).

Page 14: CLINICAL TREATMENT (CT) (RATE CODE 4525)

• The Clinical Treatment add-on is only reimbursable in conjunction with a Monthly Base Rate.
  • Reimbursement for the CT Add-On Component is subject to the following rules:
    • The members must have RRE Code 84 on their Medicaid File, or they must be in pre-admission status.
    • At least one clinical treatment service must be provided during the month to be reimbursed.
    • The CT add-on must be billed with a Monthly Base Rate (Rate Codes 4516-4518).
    • Members receiving Medication Management from PROS clinic must have at minimum, one contact with a psychiatrist or nurse practitioner in psychiatry every 3 months, or more if clinically required.
      • Contact during any of the first 3 months of the member’s admission will allow billing for that month, any prior months the member was registered with PROS, and the 2 months after the month of contact.
      • Therefore, each month the member is in contact with a psychiatrist or nurse practitioner in psychiatry will enable billing for that month and the next 2 months.

Example: If a member is seen by the physician in February, they must be seen again by the end of May to bill for May.

Allowable Monthly Billing Combinations:

Providers can submit the following possible combinations of PROS Components/Rate Codes:

• Pre-Admission Screening Services only (4510)
• Monthly Base Rate Only (4516, 4517, or 4518)
• Monthly Base Rate (4516, 4517, or 4518) + CT Add-On (4525)
• Monthly Base Rate (4516, 4517, or 4518) + CT Add-On (4525) + IR Add-On (4526)
• Monthly Base Rate (4516, 4517, or 4518) + CT Add-On (4525) + ORS Add-On (4527)
• Monthly Base Rate (4516, 4517, or 4518) + IR Add-On (4526)
• Monthly Base Rate (4516, 4517, or 4518) + ORS Add-On (4527)
• IR Add-On Only (4526)
• ORS Add-On Only (4527)

For details, please refer to the updated manual posted at: https://omh.ny.gov/omhweb/pros/pros-billing-claiming-manual.pdf.

If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].

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