CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 5 2.500000 92.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 2.750000 101.7500 37.0000
Subtotal (Total Children Is Unduplicated) 7 7.250000 194.2500 26.7931
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 27.2200 27.2200
Subtotal (Total Children Is Unduplicated) 2 2.000000 77.2200 38.6100
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.000000 16.0000 8.0000
Subtotal (Total Children Is Unduplicated) 2 2.000000 16.0000 8.0000
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Total 11.250000 287.4700 25.5529
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Number of Children (Unduplicated) With at Least One Service 7
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Center 04
Flag Claims Units Chgs Paid
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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 1 1.500000 55.5000 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
18 9.750000 231.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 19 11.250000 287.4700 0.0000