Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.79 $103.07 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 8 11 11.00 $550.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 56 60 61.00 $2958.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 27 27.00 $1309.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 12 12 12.00 $600.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 53 58 58.00 $2813.00 $48.50
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Subtotal (Total Children Is Unduplicated) 117 174 175.00 $8709.50 $49.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 5.07 $253.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.87 $43.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 49 63 110.13 $5506.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 38 51.65 $2582.52 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 41 54.10 $2704.90 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 70 97.02 $4850.87 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 2 13.14 $328.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 212 1338.62 $66931.06 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 10.29 $514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 81 112 793.13 $53837.57 $67.88
PHY -97110 PT SESSION BY LICENSED PT 98 151 884.19 $60018.84 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.53 $83.29 $54.32
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 185 269 1388.81 $94272.74 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 8 68.64 $906.09 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 269 564 291998.43 $145999.21 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 16.14 $807.15 $50.00
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Subtotal (Total Children Is Unduplicated) 304 1548 296841.36 $450205.08 $1.52
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Total 1723 297019.14 $459017.65 $1.55
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Number of Children (Unduplicated) With at Least One Authorization 315