Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 04-01-19 and 06-30-19 Date of Report: 07-21-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 703 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 2.977777 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 8.414286 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.522222 $93.3200 $37.0000
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Subtotal (Total Children Is Unduplicated) 7 7 13.914285 $93.3200 $6.7100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 1.900000 $142.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 2.183333 $163.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.166667 $12.5000 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.066667 $3.7000 $55.5300
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Subtotal (Total Children Is Unduplicated) 12 17 11.316667 $663.4500 $58.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 18 9.680159 $484.0100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 35 42 37.909523 $1895.4800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 15.966667 $798.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 28.055557 $1402.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 21 19.016666 $950.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.666667 $41.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.633333 $193.0700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 7.714287 $192.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 14 40.904761 $2045.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 409 537 1979.165860 $19791.6700 $10.0000
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.428571 $310.5200 $57.2000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.194444 $12.6400 $64.9900
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Subtotal (Total Children Is Unduplicated) 411 679 2150.336495 $33349.0900 $15.5100
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Total 703 2175.567447 $34105.8600 $15.6800
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Number of Children (Unduplicated) With at Least One Authorization 414