PROS Billing Setup in AWARDS

Introduction

This article will walk you through the BillingBuilder configuration needed to get started billing for PROS Redesign in AWARDS. The configuration is necessary to connect the new billing codes and requirements to your payers and new PROS Redesign program/s. BillingBuilder configuration is handled internally at your agency by following the instructions in this article.

Personalized Recovery Oriented Services (PROS) Redesign regulations went into effect on April 1st 2025. Medicaid and Managed Care billing is hardcoded in AWARDS and the billing code has been updated to be compliant with the Redesign billing requirements and new billing codes.

 

PROS Billing Basics: PROS is a monthly billing type, meaning that services provided throughout the month accrue units that are bundled together and billed in three Tiers.

Rate Code	Tier	PROS Units
4516	1	4 - 11
4517	2	12 - 43
4518	3	44+

There are also three add-on codes that can be billed along with the monthly tiers:

• Rate code 4526 - Intensive Rehabilitation (IR)
• Rate code 4527 - Ongoing Rehabilitation and Support (ORS)
• Rate code 4525 - Clinical Treatment (CT)

There is a separate rate 4510 for Pre-Admission services

The service documentation requirements for each are outlined in PROS Billable Service Documentation in AWARDS.

PROS Redesign Transition: PROS Redesign transition entails creating a new version of this same setup for PROS Redesign. For your new PROS Redesign program/s you will be creating:

• Program Billing Groups
• Entering Program Billing Info
• Setting Billing Rates 

In BillingBuilder, your PROS setup currently consists of:

1. One Program Billing Group Each for Medicaid and Commercial payers
   • Hardcoded billing procedures built by Foothold
   • Rates set for the old PROS procedure codes
   • Tied to your old PROS program/s
     
     
2. One Program Billing Group for Medicare
   • With procedures built and maintained by your agency internally
   • With rates tied to your old PROS program

NOTE: Don’t make changes to your old PROS billing setup. Preserve this setup intact for re-billing, reporting and auditing that may be needed in the future.

Instructions - PROS Redesign Billing Setup for Medicaid and Commercial Payers

Step 1 - Configure a Program Billing Group for Each Payer

1. Click Program Billing Groups
2. Select a Medicaid/Commercial Payer
3. Click Select
4. Click Create
5. Enter data in these fields:
    - Program Billing Group Name - it's a good idea to include the payer and billing type in the name. Ex. Medicaid/Commercial Payer name – PROS Redesign
    - Billing Type = PROS Redesign 2025
    - Revenue Code = 0240
    - Billing Provider NPI
6. Click Save
7. Click BillingBuilder and repeat this process for the rest of the Medicaid/Commercial Payers

Step 2 - Configure Program Billing Info for Each Payer/Program

1. Click Program Billing Info
2. Select Program = the name of the new PROS program, and a Medicaid/Medicare Payer 
3. Click Continue
4. Select the new Program Billing Group created above from the Dropdown (Many fields on the page will now be filled out for you)
5. Scroll down to the bottom of the page and click Continue
6. On the next page locate and click on the button Update Default Rendering/Attending Provider Info
7. On the next page, click on the Add New icon (it looks like a sheet of paper with a plus sign on it, like this: )
8. On the next page fill in these fields:
   1. First Name = a person or a part of your agency name
   2. Last Name = a person or another part of your agency name
   3. NPI = The person’s NPI or your Billing Provider NPI
   4. Effective Date = 04/01/2025
9. Click Save
10. Click on BillingBuilder in the breadcrumb trail at the top of the page
11. Repeat the above for each program/payer combination as needed

Step 3 - Enter Billing Rates for the New Program

1. Click Billing Rates
2. Select Payer = a Medicaid/Commercial Payer
3. Select Program = the name of your PROS program
4. Click Continue
5. Select the Procedure code for which you want to enter a billing rate
6. Select the Month/Year on which the rate should be effective (April 2025 is recommended)
7. Click Create
8. In the Billing Rate field, enter the rate for the selected procedure
9. Click Save
10. Click Return to Data Entry
11. Repeat steps 5-10 for all procedures
12. Repeat the above for each payer/program combination as needed

Instructions - PROS Redesign Billing Setup for Medicare

Please Note: Medicare billing is not hardcoded in BillingBuilder the way Medicaid billing is, meaning that the codes and documentation requirements for Medicare services are handled internally by your agency. 

The PROS Redesign brings a new Program Type and new Service Types, it is necessary to update all Medicare procedures to reflect the Program Types and Service Types in use. 

We have created updated copies of your Medicare billing types and procedures as follows for each payer in your database that: 

• Includes “Medicare” in the Payer name
• Currently has a Billing Type that includes “PROS” in the Billing Type Name

You will find a new billing type named PROS Redesign 2025 Medicare. This new billing type will contain copies of your existing Medicare procedures with the following modifications:

• The Program Type will be set to PROS Redesign
• The Effective Date will be set to 4/1/2025
• The Service Types will be updated to the new PROS Service Type labels

Step 1 - Configure a Program Billing Group for Each Payer

1. Click Program Billing Groups
2. Select a Medicare Payer
3. Click Select
4. Click Create
5. Enter data in these fields: 
    - Program Billing Group Name - it's a good idea to include the payer and billing type in the name. Ex. Medicare Payer name – PROS Redesign 
    - Billing Type = PROS Redesign 2025 Medicare 
    - Revenue Code = 999 
    - Billing Provider NPI
6. Click Save
7. Click BillingBuilder and repeat this process for the rest of the Medicare Payers

Step 2 - Configure Program Billing Info for Each Payer/Program

1. Click Program Billing Info
2. Select Program = the name of the new PROS program, and a Medicare Payer 
3. Click Continue
4. Select the new Program Billing Group created above from the Dropdown (Many fields on the page will now be filled out for you)
5. Scroll down to the bottom of the page and click Continue
6. If all staff who provide Medicare services have an NPI in their Human Resources record, click continue and skip to step 11 below.
7. If you have staff who provide Medicare services and who do not have an NPI in their Human Resources Record, complete steps 8 though 13.
8. On the next page locate and click on the button labeled Update Default Rendering/Attending Provider Info
9. On the next page, click on the Add New icon (t looks like a sheet of paper with a plus sign on it, like this: )
10. On the next page fill in these fields:
    1. First Name = a person or a part of your agency name
    2. Last Name = a person or another part of your agency name
    3. NPI = The person’s NPI or your Biling Provider NPI
    4. Effective Date = 04/01/2025
11. Click Save
12. Click on BillingBuilder in the breadcrumb trail at the top of the page
13. Repeat the above for each program/payer combination as needed

Step 3 - Enter Billing Rates for the New Program

1. Click Billing Rates
2. Select Payer = a Medicare Payer
3. Select Program = the name of your PROS program
4. Click Continue
5. Select the Procedure code for which you want to enter a billing rate
6. Select the Month/Year on which the rate should be effective (April 2025 is recommended)
7. Click Create
8. In the Billing Rate field, enter the rate for the selected procedure.
9. Click Save
10. Click Return to Data Entry
11. Repeat steps 5-10 for all procedures
12. Repeat the above for each payer/program combination as needed