PROS Billable Service Documentation in AWARDS

Updated April 30, 2025 20:54

Introduction

This article outlines the data entry requirements needed to bill for PROS Redesign programs in AWARDS. It’s not an exhaustive inventory of PROS Redesign documents and workflows. Every PROS program has additional forms and assessments needed for program compliance that are not included in this document. This article addresses documentation that is needed for billing in AWARDS.

Personalized Recovery Oriented Services (PROS) is a comprehensive, team-based mental health program. It integrates rehabilitation, treatment, and support services for adults with serious mental illness. On April 1st, 2025, new PROS Redesign regulations went into effect, requiring new program setup and new billing requirements in AWARDS.

Processing a New Client Into a PROS Program

The AWARDS Intake/Admission module is used to process new client intake and admission into a PROS program.

Within that module, these processes are completed using the Process Intake and Process Admission features, both of which are accessed from within client referral records.

For instructions on processing intake or admission, please see our article: Intake/Admission.

The client must be in Pending status to be eligible for billing for Pre-Admission services
- Use the Process Intake feature to make a client Pending.
The client does not need to have an Initial Service Recommendation or Initial Individualized Recovery Plan in place to be eligible for billing for Pre-Admission services.
Pre-Admission services may only be billed for two consecutive months.

PROS Related Client Setup Requirements

To be eligible for billing in a PROS Redesign program, clients must have the following:

Diagnoses – An ICD-10 diagnosis code effective during the dates of service

Face Sheet > Current Diagnoses Info or Medical > Diagnoses
Enter the client’s Diagnosis with a diagnosis date on or before any dates of service.

Entitlements – Insurance coverage and PROS component eligibility

Face Sheet > Entitlements Info > Insurance / Subsidized Payments Information
Entitlements > Certified Entitlements > Insurance / Subsidized Payments Information

Insurance

Enter the client’s Medicaid or MCO insurance, with an effective date on or before any dates of service.
Indicate whether the Medicaid/MCO insurance is Primary or Secondary.
If the client has Medicare, enter their Medicare insurance details and designate it as the Primary insurance using the Coordination of Benefits field.
If the client has commercial insurance, enter their commercial insurance details and configure the coordination of benefits field as needed.

PROS CRS Eligibility

In addition to the client’s insurance coverage, they will need an entitlement record indicating their eligibility for PROS CRS once they are enrolled in the program.
The PROS-CRS entitlement is not required to bill for Pre-Admission services.

PROS IR, ORS, or CT Eligibility

They also need entitlement records indicating their eligibility for any additional PROS components the client is receiving outside of CRS (PROS-IR, PROS-ORS, and PROS-CT).
The entitlements must be effective during the dates of service being billed.

Authorizations – If the client’s insurance requires authorizations, enter the authorization information in Entitlements > Certified Entitlements > BillingBuilder Insurance Authorizations.

PROS Billable Service Documentation

Initial Services Recommendation

The ISR must be in place beginning on the day of admission. AWARDS looks for a completed ISR (if done as part of Plans & Reviews, it must have an Effective date) to determine the eligibility of services for billing during the client’s first 60 days in the PROS program.

The ISR may be done as an Immediate Needs Plan in Plans & Reviews or as a FormBuilder form located on the Services – Individual menu or included in Progress Notes.

Note: if your PROS Redesign program is using a FormBuilder form for the ISR instead of Plans & Reviews, let the Help Desk know so they can disable the default requirement for an Immediate Needs Plan to be used to support the first 60 days.

Individualized Recovery Plans

Individualized Recovery Plans identify the services the client will receive in the PROS program. Services are not considered eligible for billing unless they have a corresponding service/intervention on the client’s current IRP.

IRPs are completed under Services – Individual > Plans & Reviews.
The Initial IRP must have an Effective Date before the client’s 61st day in the PROS program.
IRP Reviews must be completed and marked effective every 180 days.

Service Documentation with Progress Notes/Group Activities/Group Notes

Individual Progress Notes

Individual Progress Notes must be at least 15 minutes in duration to be eligible for billing.

Service Plan Linked notes are not required; however, the service type on the Progress Note must match a PROS service identified on the client’s current IRP to be eligible for billing.

Locations

Onsite - the locations counted towards Onsite units are:

“This Program Site”
“Co-Located Site”
Any location that includes the word “Telehealth”

Offsite - all other locations are considered Offsite

Telehealth

Telehealth services must take place in one of the following locations:

Telehealth - Video - Home
Telehealth - Video - Not at Home
Telehealth - Audio Only - Home
Telehealth - Audio Only - Not at Home

Face to Face

All PROS services must be documented as Face to Face Yes except:

Telehealth - Audio Only - Home
Telehealth - Audio Only - Not at Home

Group Notes

Group Notes must be at least 30 minutes in duration to be eligible for billing.
Location requirements are the same as for individual Progress Notes.

Billable services must take place while the client was not hospitalized.

Documentation Requirements for Each Billing Code

Pre-Admission – Rate Code 4510

Client has had Intake processed and is in “Pending” status as of the end of the month being billed.
No ISR or IRP is required prior to being admitted.
Can only be billed for two consecutive months.
Client has at least one 15 minute individual service or one 30 minute group service in the month
If an individual received pre-admission services but is enrolled by the last day of the month, all services in the month of admission are included in the unit calculation for the month.
You cannot bill for both pre- and post-admission services in the same month, only one or the other.

CRS Tiers

Tier 1 - 4-11 units (Rate code 4516)

Tier 2 – 12-43 units (Rate code 4517)

Tier 3 – 44+ units (Rate code 4518)

Client is admitted to the program.
Has an entitlement for “PROS-CRS” entered in Entitlements > Eligibilities with an effective date equal to the admission date.
Has an Initial Service Recommendation (ISR) completed – this is valid for the first 60 days after admission OR has an Individualized Recovery Plan (IRP) in effect if the client has been enrolled in the program for more than 60 days.
The Service type on the Progress Note or Group Note must match a service type selected for a service/intervention on the client’s current IRP.
Service Plan Linked Notes are not required.
Must have at least 4 unadjusted CRS units in the month.

Intensive Rehab (IR) - Rate Code 4526

Client is enrolled in the program.
Has an entitlement for “PROS-IR” entered in Entitlements > Eligibilities with an effective date on or before the date of any IR services.
At least one service in the month that starts with “IR“; at least 15 minutes for individual Progress Notes and 30 minutes for Group Notes.
The Service type on the Progress Note or Group Note must match a service type selected for a service/intervention on the client’s current IRP.
Service Plan Linked Notes are not required.
Must have at least 6 unadjusted units in the month. Can be a combination of IR, CRS, and CT services.

Ongoing Rehab and Support (ORS) - Rate Code 4527

Client is enrolled in the program.
Has an entitlement for “PROS-ORS” entered in Entitlements > Eligibilities with an effective date on or before the date of any ORS services.
At least one service in the month that starts with “ORS“; at least 15 minutes for individual Progress Notes and 30 minutes for Group Notes.
The Service type on the Progress Note or Group Note must match a service type selected for a service/intervention on the client’s current IRP.
Service Plan Linked Notes are not required.
Must have at least 4 unadjusted ORS units in the month.

Clinic Treatment (CT) - Rate Code 4525

Client must also be eligible for billing one of the PROS CRS Tiers.
Has an entitlement for “PROS-CT” entered in Entitlements > Eligibilities with an effective date on or before the date of any CT services.
The Service type on the Progress Note or Group Note must match a service type selected for a service/intervention on the client’s current IRP.
The note must be face to face.
The Note Writer must have an NPI enter in Human Resources > Credentials.
Service Plan Linked Notes are not required.
Must have at least 1 unadjusted CT unit in the month
If the service type is CT-Medication Management the client must have a Psychiatrist Note written within 90 days preceding the Medication Management service.

Medicare/Medicaid coordination of benefits

AWARDS is equipped to coordinate benefits between Medicare and Medicaid insurances when a client is dually eligible and receives services that meet the requirements for both.

When a dually-eligible client receives a service that meets the requirements to bill Medicare as well as the requirements to bill Medicaid for Clinical Treatment for the month, Medicare should be billed prior to Medicaid.
When Medicare invoices are created before Medicaid invoices are created, then the Medicaid claim for a dually-eligible person will include the information that Medicare has been billed. If Medicare payments have been posted for dates of service in the month you are billing Medicaid, those payments will be reflected in the Medicaid invoices.
AWARDS does not require that Medicare invoices be created before Medicaid invoices Medicaid invoices will have Medicare payment information inserted into the claim file when the following are true:

- - - The Medicare invoice batch has been posted to A/R.
    - The Medicare invoices have been submitted to Medicare for payment.
    - The Medicare payments have been entered into a remittance worksheet and the worksheet has been posted.
    - The Medicaid invoices are created AFTER the Medicare payments have been posted.

PROS UNIT Calculation

Unadjusted Units:

Progress Note - 15 minutes = 1 unit
Group Note - 30 minutes = 1 unit

Adjusted Units:

Service provided in Offsite locations, as defined on Page 4 can be doubled after minimum unit requirements are met

Daily Units:

Each client can accumulate a maximum of 5 unadjusted units per service day. Unadjusted units over and above the maximum of 5 must be discarded from the daily unit count. If a client has a mix of onsite and offsite units on a given day, discard the onsite units first.
Once you have trimmed down the number of unadjusted units to 5, double the offsite units to determine the number of adjusted units accumulated by the client for the day.

Minimum Unit Requirements for Each Procedure Per month:

These requirements are calculated using Unadjusted Units only

Pre-admission (4510) - 1 unadjusted unit of any service type in the month
CRS (4516, 4517, 4518) - 4 unadjusted units from CRS services in the month
IR (4526) - 6 unadjusted units in the month. One unit must be from an IR service. The remaining 5 units can be a combination of IR, CRS, and CT services if the IR procedure is to be billed together with the corresponding CRS and CT procedures
ORS (4527) - 4 unadjusted units from the ORS service type in the month
CT (4525) - 1 unadjusted unit in the month from a CT service. Since CT must be billed with a CRS procedure, there also must be a minimum of 4 unadjusted units from CRS services in the month

Units to Report on Invoices

If the minimum unit requirements for any procedure are met, calculate the units to report on the invoices as follows:

Pre-admission (4510) - Double the offsite units accumulated in the month for all service types and add the onsite units.
CRS (4516, 4517, 4518) - Double the offsite units accumulated in the month for all service types and add the onsite units.
IR (4526) - Double the offsite units accumulated in the month for IR service types only and add the onsite units.
ORS (4527) - Double the offsite units accumulated in the month for ORS service types only and add the onsite units.
CT (4525) - Double the offsite units accumulated in the month for CT service types only and add the onsite units.