Guidelines for Utilization Management for Personalized Recovery Oriented Services (PROS)
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Guidance governing utilization management for PROS programs in Medicaid managed care, directed to Mainstream MMCOs, HARPs, HIV-SNPs, and MAP plans and describing admission, continued stay, discharge criteria, UM triggers, and assessment timelines.
No material clinical or coverage changes in this revision.
Coverage and Utilization Criteria for PROS
inv-01: Admission criteria
Covered when ALL of the following are met:
Use of LOCUS tool is optional; individuals in LOCUS Levels 2-4 may be appropriate.
inv-02: Assessment and planning timelines
inv-03: Utilization Management review triggers
Concurrent UM review may be initiated when member has at least 12 months enrollment with 6 months continuous engagement AND any of the following triggers are present:
Insurers may conduct prospective concurrent reviews under these conditions.
inv-04: Discharge criteria
PROS Program Levels and Eligibility
Clinical Treatment Component
inv-16: Clinical Treatment component
Provider Responsibilities and Authorization Rules
Prior authorization prohibition
Prior authorization is prohibited for PROS; concurrent authorizations are no longer required but may be performed based on utilization management criteria.
Provider responsibilities for admission, assessment, and monitoring
Follow program and UM criteria for enrollment, assessment, and ongoing review per OMH/PROS requirements (age, diagnosis, functional disability, licensed practitioner recommendation, and dated signed recipient attestation).
- Admission requirements: Age ≥18; designated mental health diagnosis; functional disability due to severity/duration; recommendation by a licensed practitioner of the healing arts; individual's consent documented by a dated and signed recipient attestation form.
- Complete initial screenings and assessments within 45 days and develop initial IRP within 60 days (use ISR until IRP complete).
- IRP reviewed at least every 6 months; IR/ORS services reassessed at least every 3 months. (See UM triggers for concurrent review conditions.)
Required documentation and timelines
Document the individual's consent using a dated and signed recipient attestation form and record all components and services on the Initial Services Recommendation (ISR) until the initial IRP is completed.
- Initial screenings and assessments must be completed within 45 days of admission.
- Initial IRP must be developed within 60 days of admission; ISR used until IRP completion.
- IRP must be reviewed at minimum every 6 months.
UM review triggers and potential review actions
Utilization management reviews may be initiated when a member has been enrolled ≥12 months with ≥6 months continuous engagement and meets specified clinical triggers; failure to meet UM criteria may prompt review actions that could affect coverage or case management.
- Triggers include: current AOT court order; identified by LGU as receiving Enhanced Service Package via Voluntary Agreement in lieu of AOT; expired AOT within past year; recent discharge from State Psychiatric Centers or corrections-based units (within 18 months); recent transition off ACT team to lower level (within 18 months); HUD Category One literal homelessness; high inpatient/ED utilization (see thresholds).
- Insurers may conduct prospective concurrent reviews under these conditions.
High Utilization Indicators and Coding Flags
Key Definitions
Background
PROS (Personalized Recovery Oriented Services) is a comprehensive, recovery‑oriented program for adults with serious mental illness that integrates rehabilitation, treatment, and support to promote recovery and attainment of life goals across community settings. The model is person‑centered and strengths‑based, delivering a mix of group and individual services designed to help participants overcome mental health barriers and pursue goals such as employment, education, independent living, and improved social relationships and wellness. (See program vision and definition.)
The PROS service model consists of four components: Community Rehabilitation and Support (CRS), Intensive Rehabilitation (IR), Ongoing Rehabilitation and Support (ORS), and an optional Clinical Treatment component. All programs provide CRS, IR, and ORS; Clinical Treatment is optional and, as of 2022, is included in 68 of 80 programs statewide. CRS functions as the backbone of PROS, while IR, ORS, and Clinical Treatment are billed as add‑on components. (See program model and statewide statistics.)
These guidelines frame utilization management expectations for Medicaid managed care plans and PROS providers, including enrollment eligibility, required assessments and individualized recovery planning timelines, and circumstances that may prompt utilization management review. Key program features include documented informed consent via a dated and signed recipient attestation form and a schedule of assessments: initial screenings and assessments within 45 days of admission and an initial Individualized Recovery Plan (IRP) within 60 days, with the IRP reviewed at least every 6 months. For individuals receiving IR or ORS, services on the IRP must be reassessed at least every 3 months. (See eligibility, admission, and assessment timelines.)
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