Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 5 6 6.00 $360.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 21 21 21.00 $1018.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 40 42 42.00 $2037.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 13 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 37 36.35 $1762.98 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 94 99 99.00 $4801.50 $48.50
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Subtotal (Total Children Is Unduplicated) 133 219 218.35 $10730.08 $49.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 19.14 $957.15 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 3.89 $194.41 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.45 $122.26 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.57 $78.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 5 6.73 $336.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 3 5.62 $140.60 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 73.86 $3692.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 41 53 461.64 $23081.93 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 135 162 1344.29 $91250.15 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 13.43 $729.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 79 97 759.93 $51583.95 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 6.57 $357.05 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 3.07 $3.07 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 192 234 1787.28 $121320.54 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 10.86 $143.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 77 101 3337.35 $1668.68 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.43 $621.43 $50.00
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Subtotal (Total Children Is Unduplicated) 256 687 7852.09 $299281.69 $38.11
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Total 906 8070.44 $310011.77 $38.41
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Number of Children (Unduplicated) With at Least One Authorization 270