Personalized Recovery Oriented Services program updates

The Personalized Recovery Oriented Services (PROS) program has revised their program model along with elements of its billing and reimbursement models. The changes outlined below will take effect on April 1, 2025.

A simplified model by redefining the PROS unit, eliminating the concept of program participation time, and reducing the number of monthly base rate tiers from five (5) to three (3).

1. New base rate tiers

The updated model will have fewer rate tiers. A set of three‑monthly base rate tiers will replace the five‑tier system currently used by PROS.

Current PROS model
	Service units	Rate codes
Tier 1	2‑10	4520
Tier 2	13‑27	4521
Tier 3	28‑43	4522
Tier 4	44‑60	4523
Tier 5	61+	4524

New PROS model
	Service units	Rate codes
Monthly – Tier 1	4‑11	4516
Monthly – Tier 2	12‑43	4517
Monthly – Tier 3	44+	4518

The monthly base rate will be calculated by adding all PROS units accrued within a one‑month period, including units from these services:

• Community Rehabilitation and Support (CRS) 
• Intensive Rehabilitation (IR)
• Ongoing Rehabilitation and Support (ORS)
• Clinical Treatment (CT) service

2. Revised coding matrix

After April 1, 2025 PROS providers submitting managed care claims will need to use the new rate code, procedure code, and modifier combinations shown in the coding matrix below.

3. Service adjustments

Program updates will include:

• The addition of Complex Care Management and Peer Support under Community Rehabilitation and Support (CRS).
• A consolidation of certain CRS services into a single Psychosocial Rehabilitation Service.
• Licensed Occupational Therapists and Certified Psychiatric Rehabilitation Practitioners (CPRPs) now included in the pool of qualified professionals.
• Moving Cognitive Remediation from the CRS component to the Intensive Rehabilitation (IR) component.

4. Unit definitions and billing rules

A unit is defined as:

• 15 minutes for individual/collateral services.
• 30 minutes for group services.
  • Off‑site services count as double units for calculation purposes (once minimum duration requirements are met).

5. Minimum service requirements:

• At least 4 CRS units per month are required for monthly base rate billing.
• At least 6 units of service, including 1 IR service, be delivered monthly to bill IR as an add on.

6. Daily unit max – individual and group combined

• Onsite services ‑ 5 units per day
• Off‑site services ‑ 10 units per day

For full details on these changes, please refer to the official guidance provided by the New York State Office of Mental Health (OMH) at, https://omh.ny.gov/omhweb/bho/pros‑redesign‑billing‑reimbursement‑changes.pdf.

For questions or more information, contact Provider Services at 800‑450‑8753.