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: 07-01-18 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 2633 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 7 7 6.585714 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 32.738096 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 12.427778 $459.8300 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 15 51.751588 $459.8300 $8.8900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 11 9.983334 $484.1900 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.755556 $41.6100 $23.7000
EXIT -EXIT EXIT ASSESSMENT 5 5 6.866667 $343.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 10.388889 $779.1700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 18 18 17.372222 $1302.9200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 7.705555 $577.9100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 14.888889 $826.3300 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 3.550000 $177.5000 $50.0000
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Subtotal (Total Children Is Unduplicated) 49 75 74.511112 $4643.9700 $62.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.933333 $96.6700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 2 2.011111 $462.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 63 74 56.346032 $2817.3000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 116 160 450.562701 $22528.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 82 161.061111 $8053.0600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 104 290.060316 $14503.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 73 141.000001 $7050.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.922222 $123.0600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 7 16.633333 $1219.5500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 30.317459 $757.9400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 41 334.488889 $16724.4600 $50.0000
INTR -T1013 INTERPRETER 2 2 26.333334 $1316.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 945 1978 18118.775394 $181187.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 21.342857 $1524.7400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 19.857143 $1135.8300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 6.400000 $457.2200 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 1.205555 $78.3600 $65.0000
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Subtotal (Total Children Is Unduplicated) 951 2543 19685.250791 $265061.2700 $13.4600
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Total 2633 19811.513491 $270165.0700 $13.6400
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Number of Children (Unduplicated) With at Least One Authorization 957