Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3741 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.800000 $29.6000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 51 51 221.728572 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 14 14 373.714287 $13827.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 65 66 596.242859 $13857.0300 $23.2400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 17 12.994520 $630.2300 $48.5000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 155 157 311.750000 $15587.5000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 19.500000 $1462.5000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 187 206 386.244520 $20162.2200 $52.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 4.300000 $215.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 228 242 269.369300 $13468.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 29.535714 $738.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 89 102 180.247615 $9012.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.533333 $63.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 35 56.116665 $2805.8300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 49 82.049998 $4102.4900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 79 136.438887 $6821.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.533333 $63.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 28 204.257143 $10212.8600 $50.0000
INTR -T1013 INTERPRETER 128 139 335.426190 $16771.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 902 1248 6532.974725 $65329.7200 $10.0000
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 21.000000 $1500.2400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.285714 $59.4900 $13.8800
TRAV -TRAVS Travel by mile 933 1525 6872.922346 $3058.4500 $0.4400
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Subtotal (Total Children Is Unduplicated) 967 3469 14736.990963 $144223.2100 $9.7900
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Total 3741 15719.478342 $178242.4600 $11.3400
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Number of Children (Unduplicated) With at Least One Authorization 983