CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2014 ending 03/31/2014 Date of Report:06/03/2014 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 12 6.750000 249.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 7.500000 277.5000 37.0000
Subtotal (Total Children Is Unduplicated) 14 17.750000 545.7500 30.7465
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 40.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
Subtotal (Total Children Is Unduplicated) 3 4.500000 237.6400 52.8089
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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 24.250000 799.3900 32.9645
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Number of Children (Unduplicated) With at Least One Service 14
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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 3 3.500000 205.5000 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
31 17.750000 482.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 34 21.250000 688.3900 0.0000
Center 57
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 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 3.000000 111.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 3.000000 111.0000 0.0000