Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 807 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 28 28 16.566666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 28 28 16.566666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 1.355555 $65.7400 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.622223 $31.7700 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.116667 $5.9600 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.600000 $30.6300 $51.0500
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Subtotal (Total Children Is Unduplicated) 8 8 2.694445 $134.1000 $49.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 84 23.189682 $1159.4900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.411112 $70.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.644445 $132.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.111111 $55.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 19 102.142856 $5107.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 606 654 4701.747612 $47017.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 16.000000 $1143.0400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.000000 $171.4800 $57.1600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 27.142857 $1552.5700 $57.2000
TRAV -TRAVS Travel by mile 1 1 2.142857 $0.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 640 771 4881.532532 $61410.5100 $12.5800
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Total 807 4900.793643 $61544.6100 $12.5600
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Number of Children (Unduplicated) With at Least One Authorization 668