PROS program billing and reimbursement changes
Governs proposed billing, coding, and reimbursement changes for New York State PROS programs and requirements for Medicaid Managed Care Plans and PROS providers; applies to MMCPs, HARPs, HIV SNPs, MAP Plans, and PROS providers in New York State.
Redefines the PROS unit and moves from a five-tier to a three-tier monthly base rate structure with new rate codes 4516–4518.
Off-site services will count as two units for purposes of calculating tiered monthly base rate units.
Minimum monthly unit thresholds: at least 4 CRS units to bill the monthly base rate and at least 6 units including one IR to bill the IR add-on.
PROS providers required to report actual units on claims to support state monitoring.
Billing and Unit Calculation Rules
Billing criteria and unit calculation rules
Covered when the following unit-counting, minimum-monthly threshold, and claiming rules are met for an individual in a calendar month:
ALL of the following
ALL of the following
- At least 4 CRS units must be provided during the calendar month to bill the PROS monthly base rate.>= 4 CRS units
These services may be provided on-site or off-site but minimum duration rules apply: at least 60 minutes of individual CRS services or 120 minutes of group CRS services over the month (i.e., off-site services do NOT count double toward meeting this minimum duration).
ALL of the following
- One PROS unit = 15 continuous minutes of individual service or 30 continuous minutes of group service.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.