Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 07/01/08 and 09/30/08 Date of Report: 11-18-08 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 7 7.07 $424.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 16 22 33.00 $1650.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 8 8 8.00 $444.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 39 39 44.00 $3300.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 13.00 $975.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 26 26 27.00 $2025.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 8.00 $444.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 48 48 54.00 $4050.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 30 30.00 $1455.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 26 26.00 $1261.00 $48.50
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Subtotal (Total Children Is Unduplicated) 126 243 269.07 $17057.00 $63.39
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 25 35.00 $52500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 12.70 $635.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 228 645 1289.00 $64450.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 235 316 636.57 $31828.57 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 152 304.00 $15200.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 136 177 354.00 $17700.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 186 240 480.00 $24000.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 7.73 $193.34 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 33 54.28 $1356.96 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 17 18 141.57 $7078.58 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 281 2137.61 $106880.60 $50.00
INTR -INTR INTERPRETER 7 10 28.71 $1435.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 74 97 610.98 $41473.56 $67.88
PHY -97110 PT SESSION BY LICENSED PT 113 148 693.07 $47045.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.71 $364.72 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.25 $10.84 $43.00
SENS -V5264 EARMOLD 3 4 5.11 $95.68 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 149 189 1027.25 $69730.03 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 24.00 $316.80 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 3.00 $300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 259 465 944.43 $472.21 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.57 $328.57 $50.00
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Subtotal (Total Children Is Unduplicated) 275 2817 8804.57 $484396.73 $55.02
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Total 3060 9073.63 $501453.72 $55.26
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Number of Children (Unduplicated) With at Least One Authorization 277