CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 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 11 7.500000 277.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 141 89.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 563 1588.250000 58783.7500 37.0116
Subtotal (Total Children Is Unduplicated) 564 1685.000000 59061.2500 35.0512
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 177 262.000000 19564.3700 74.6732
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 71 131.500000 9900.0000 75.2852
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 28.000000 2084.3400 74.4407
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 248 388.500000 21589.5000 55.5714
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 41.000000 3075.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 9 38.000000 1900.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 215.2500 43.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 329 947.000000 61506.9100 64.9492
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 64 91.250000 4562.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 21 18.500000 462.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 17.000000 850.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 14.000000 700.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 24.000000 1200.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 15.500000 775.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 91.000000 2275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 331 1724.000000 86200.0000 50.0000
INTR-T1013-INTERPRETER 2 12.000000 468.0000 39.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 30 73.000000 730.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 63 338.000000 23586.1600 69.7815
OCCT-97530HM-OT SESSION BY OT ASST 7 42.250000 2416.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 98 495.250000 33103.8800 66.8428
PHY-97110HM-PT SESSION BY PT ASST 4 20.500000 1171.7800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 204 1098.000000 77607.7800 70.6810
TRAV-TRAVS-Travel by mile 1174 78996.00000 34872.8000 0.4415
Subtotal (Total Children Is Unduplicated) 1299 83072.75000 271044.6000 3.2627
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Total 85704.750000 391612.7600 4.5693
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Number of Children (Unduplicated) With at Least One Service 1859
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Center 06
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 4.000000 261.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 4.000000 261.0000 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 3588 79670.250000 250899.3300 250899.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 610 920.250000 47688.5000 0.0000
T 0 0.000000 0.0000 0.0000
301 3154.000000 18570.1800 0.0000
Other 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 4500 83746.000000 317270.5100 250899.3300
Center 52
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 12 15.000000 783.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.4400 40.0000
T 3 6.000000 287.8700 266.8700
63 80.750000 3248.6700 1171.0900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 79 102.750000 4390.9800 1477.9600
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
136 123.750000 7843.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 136 123.750000 7843.6600 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 0 0.000000 0.0000 0.0000
1223 1519.250000 59725.2200 2460.7200
Other 61 209.000000 2121.3900 2121.3900
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Total 1284 1728.250000 61846.6100 4582.1100