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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 628 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 33 33 20.841269 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 33 33 20.841269 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.219842 $164.3800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.100000 $5.1100 $51.0500
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Subtotal (Total Children Is Unduplicated) 4 4 3.319842 $169.4800 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 62 32.457142 $1622.8600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.527778 $13.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.422222 $10.5600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 14 120.857142 $6042.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 487 509 3589.954748 $35899.5900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.857143 $418.4300 $71.4400
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Subtotal (Total Children Is Unduplicated) 509 591 3750.087287 $44008.0400 $11.7400
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Total 628 3774.248398 $44177.5200 $11.7000
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Number of Children (Unduplicated) With at Least One Authorization 537