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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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 5.23 $314.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 22 27 46.00 $2300.00 $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 4 4 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.00 $375.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.00 $333.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 20.00 $1110.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 58 58 105.00 $7875.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 16 16 26.00 $1950.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 33 33 57.00 $4275.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 94.00 $5217.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 26 38.00 $2850.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 36 36.00 $1746.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 32 35 35.00 $1697.50 $48.50
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Subtotal (Total Children Is Unduplicated) 164 321 492.23 $31183.00 $63.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 27 37.00 $55500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 10.84 $541.91 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 224 597 1193.00 $59650.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 250 308 616.04 $30801.91 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 120 149 298.00 $14900.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 145 182 364.00 $18200.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 198 242 484.00 $24200.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 5 5 9.90 $247.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 33 86.32 $2157.98 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 20 22 226.43 $11321.45 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 260 2094.35 $104717.32 $50.00
INTR -INTR INTERPRETER 7 10 29.14 $1457.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 65 79 443.39 $30097.54 $67.88
PHY -97110 PT SESSION BY LICENSED PT 124 151 756.82 $51372.75 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 6.00 $6.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 0.25 $16.39 $65.00
SENS -V5264 EARMOLD 3 3 3.44 $64.48 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 144 170 959.66 $65141.52 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.79 $142.37 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 3 14.71 $1471.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 276 452 1352.64 $676.32 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 6.57 $328.57 $50.00
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Subtotal (Total Children Is Unduplicated) 291 2709 9004.29 $473512.58 $52.59
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Total 3030 9496.52 $504695.58 $53.15
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Number of Children (Unduplicated) With at Least One Authorization 298