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Office of Mental Health

Letter Regarding PROS and DOH Waiver Programs Released

February 3, 2011

OMH PROS Providers:

This letter is an advisory addressing a long-standing problem for PROS providers. Some PROS providers have been serving clients in their PROS that are also in the Traumatic Brain Injury Waiver (TBI), Long Term Home Health Care Program (LTHHCP), or the Nursing Home Transition and Diversion Medicaid Waiver (NHTD) and have not been reimbursed by Medicaid for their PROS services.

OMH & DOH have come to an agreement to allow some PROS services for these clients to be reimbursable. The necessary technical adjustments to WMS and eMedNY have been made, establishing reimbursement edits and updating the restriction code file for PROS enrollees who are "co-enrolled" in the three DOH waivers.

For these waiver enrollees who have been using PROS services prior to January 27, 2011, the effective date for WMS enrollment in PROS will be Thursday 1/27/2011. For waiver enrollees admitted to PROS after January 27, 2011, the effective date will be their date of admission. PROS providers will need to switch the registry status in CAIRS for these individuals to register with Medicaid so they will come back through the nightly batch. OMH will then add the appropriate codes. CAIRS registration notification for these enrollees will be the same as for all other registrations.

Limits on PROS services for PROS clients in these waiver programs:

  • CRS services for Level 1, rate code 4520 and Level 2, rate code 4521 only. This means that they can receive up to 27 Medicaid reimbursed units of CRS service a month. (Medicaid claims for CRS Levels 3 through 5 will be denied.)
  • Clinic services at the PROS, rate code 4525, can also be provided and reimbursed for clients in these waiver programs if they choose.
  • IR/ORS services will not be reimbursed for clients in these waivers because similar services are offered through the waiver.

We appreciate that you as providers have been serving these clients without being reimbursed while awaiting OMH and DOH to resolve this problem. The agreement is, however, only prospective from the effective date (i.e., PROS services delivered in January 2011) and no retrospective reimbursement will be enabled.

We thank you for your patience.

Comments or questions about the information on this page can be directed to the Bureau of Financial Planning.