Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 302 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 35 35 17.661112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 35 17.661112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 15 10.477778 $508.1700 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.711111 $36.3000 $51.0500
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Subtotal (Total Children Is Unduplicated) 14 17 11.188889 $544.4800 $48.6600
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 14 14 16.977778 $848.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 67 78.866668 $3943.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 30 40.100001 $2005.0100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.744444 $37.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 114 113.611115 $5680.5800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.766667 $88.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 21 90.280951 $4514.0500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 2 8.366667 $597.7200 $71.4400
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Subtotal (Total Children Is Unduplicated) 175 250 350.714291 $17715.1300 $50.5100
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Total 302 379.564292 $18259.6100 $48.1100
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Number of Children (Unduplicated) With at Least One Authorization 213