Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 10 10 5.64 $208.61 $37.00
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Subtotal (Total Children Is Unduplicated) 10 10 5.64 $208.61 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 10 33.80 $2028.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 5.07 $237.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.06 $724.43 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 10.00 $500.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 25 33 60.92 $3857.05 $63.31
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 4.08 $203.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 20 30.00 $1500.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 20 22 28.17 $1408.32 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 3 2.30 $57.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 49 56.69 $2834.64 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 9 10.08 $252.08 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 32 43.75 $2187.37 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 7 8.23 $205.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 39 43 56.72 $2836.02 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 11.89 $297.26 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 47 49 597.57 $14939.30 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 202 262 2163.57 $108178.45 $50.00
INTR -INTR INTERPRETER 16 16 131.93 $6596.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 155 199 1037.85 $70449.07 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 8 54.00 $2933.29 $54.32
PHY -97110 PT SESSION BY LICENSED PT 208 272 1659.64 $112656.64 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 16.89 $917.62 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 2 1.07 $19.97 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 331 443 2916.65 $197982.07 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.86 $535.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 15.43 $203.66 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 9 10.47 $1046.67 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 11 119.50 $5975.01 $50.00
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Subtotal (Total Children Is Unduplicated) 526 1483 8992.32 $538218.31 $59.85
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Total 1526 9058.89 $542283.97 $59.86
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Number of Children (Unduplicated) With at Least One Authorization 534