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: 01/01/08 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 21 22 20.57 $761.09 $37.00
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Subtotal (Total Children Is Unduplicated) 21 22 20.57 $761.09 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 20 115.97 $6957.95 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 8 14.37 $672.36 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 9 31.39 $3754.58 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 25.29 $3160.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 124 151 206.00 $10300.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.00 $242.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.00 $242.50 $48.50
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Subtotal (Total Children Is Unduplicated) 149 203 406.01 $25476.11 $62.75
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 14 19.48 $973.78 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 74 83 112.00 $5600.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 3.00 $75.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 50 111.08 $5553.82 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 6 7.13 $178.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 80 175.45 $8772.60 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 17 30.01 $750.21 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 56 128.16 $6407.95 $50.00
CONPP -CONPP CONSULT, PT, PHONE 12 17 25.17 $629.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 80 187.85 $9392.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 17 26 35.42 $885.39 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 21 21 540.14 $13503.57 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 80 114 3050.57 $76264.29 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 53 54 553.53 $27676.42 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 32.86 $821.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 315 539 8295.59 $414779.72 $50.00
INTR -INTR INTERPRETER 44 58 372.86 $18642.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 238 446 4616.08 $313339.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 19 25 281.18 $15273.61 $54.32
PHY -97110 PT SESSION BY LICENSED PT 317 607 6821.25 $463026.40 $67.88
PHY -97110HM PT SESSION BY PT ASST 17 17 79.77 $4332.86 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 14.00 $14.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 5 4.50 $2250.00 $500.00
SENS -V5264 EARMOLD 4 5 3.44 $64.48 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 526 972 11178.40 $758789.70 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 38.64 $2099.07 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 164.15 $2166.75 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 16 31 41.50 $4150.01 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 2.00 $1.00 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 9 9 46.64 $2332.15 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 18 426.07 $21303.57 $50.00
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Subtotal (Total Children Is Unduplicated) 795 3401 37404.91 $2190550.36 $58.56
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Total 3626 37831.49 $2216787.56 $58.60
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Number of Children (Unduplicated) With at Least One Authorization 802