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Personalized Recovery Oriented Services (PROS) Redesign

Posted Feb 14, 2025

Billing and Reimbursement Changes Effective April 1, 2025

A printable PDF is available here.

 

The New York State (NYS) Office of Mental Health (OMH) is launching a redesign of the Personalized Recovery Oriented Services (PROS) program effective April 1, 2025. These changes will affect Healthfirst’s Medicaid, Personal Wellness Plan (HARP), Connection Plan (CNX), and Complete Care (CC) plans.

What are Personalized Recovery Oriented Services (PROS)?

PROS is a comprehensive team-based, site-based program model that integrates rehabilitation, treatment, and support services for adults (18+) with serious mental illness. It consists of four components: Community Rehabilitation and Support (CRS), Intensive Rehabilitation (IR), Ongoing Rehabilitation and Support (ORS), and Clinical Treatment (CT).

PROS Rates and Code Changes

Billing Guidelines Update

As part of the redesign, the following changes will be made to PROS billing guidelines:

  1. The Community Rehabilitation and Support (CRS) base monthly rate component will be restructured from its current five-tier form to a three-tier form.
  2. The existing CRS rate codes, 4520 – 4524, will be eliminated and no longer used for PROS reimbursement. Claims billed with the retired rates 4520-4524 will be denied after March 31, 2025.

Updated PROS Monthly Base Rate Coding Taxonomy

The grid below details the new rate code, procedure code, and modifier combinations for CRS:

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 +

Note: PROS billing codes remain unchanged for all other services outside of CRS.

More Information

For more information about the PROS redesign check out the following resources:

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am–5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).

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