CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2013 ending 06/30/2013 Date of Report:08/19/2013 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 1.500000 55.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 135 270.500000 9953.0000 36.7948
Subtotal (Total Children Is Unduplicated) 137 272.000000 10008.5000 36.7960
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1 1.000000 48.5000 48.5000
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 279.8000 139.9000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 49 950.000000 23750.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 17.500000 1187.9000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 22.000000 1493.3600 67.8800
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 13 35.000000 350.0000 10.0000
Subtotal (Total Children Is Unduplicated) 70 1033.500000 27411.0600 26.5226
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Total 1306.500000 37468.0600 28.6782
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Number of Children (Unduplicated) With at Least One Service 207
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Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 2.000000 279.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 279.8000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
36 744.000000 18600.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 744.000000 18600.0000 0.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3 2.500000 92.5000 92.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
346 269.000000 9897.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 349 271.500000 9990.0000 92.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
64 32.000000 2156.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 64 32.000000 2156.7200 0.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 10.0000 10.0000
13 206.000000 5150.0000 0.0000
Other 23 50.000000 1281.5400 1281.5400
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Total 37 257.000000 6441.5400 1291.5400