Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 31 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 1 1 2.142857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.966667 $109.7700 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 5.109524 $109.7700 $21.4800
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 10 10 10.857143 $542.8600 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 2 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 11 12 12.857143 $644.9600 $50.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.866667 $71.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.200000 $60.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 5.395238 $269.7700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 2.533333 $126.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 3.714286 $185.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 39.285714 $2806.5800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.142857 $295.9700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714286 $1265.5100 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 2 0.428571 $15.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 14 17 78.280952 $10097.7300 $128.9900
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Total 31 96.247619 $10852.4500 $112.7600
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Number of Children (Unduplicated) With at Least One Authorization 25