Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 624 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 3.200000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.200000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 3 3 4.577778 $228.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.544444 $40.8300 $74.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.544444 $40.8300 $74.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 1.583333 $118.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 2.088889 $115.9300 $55.5000
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Subtotal (Total Children Is Unduplicated) 10 15 10.338888 $593.7300 $57.4300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 14.688889 $734.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 44 55 65.227778 $3261.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 13.216667 $660.8400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 14.305554 $715.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 17 12.961111 $648.0600 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 3.633333 $266.3900 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 10 33.704762 $1685.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 364 470 2002.144469 $20021.4400 $10.0000
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $89.8800 $57.2000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.200000 $13.0000 $65.0000
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Subtotal (Total Children Is Unduplicated) 368 607 2161.653992 $28095.9600 $13.0000
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Total 624 2175.192880 $28689.6900 $13.1900
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Number of Children (Unduplicated) With at Least One Authorization 369