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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 3.79 $103.07 $27.23
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 7.00 $420.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 8.00 $1000.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 17 22 22.00 $1100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 118 158 159.00 $7711.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 49 60 60.00 $2910.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 18 18 18.00 $900.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 134 163 164.90 $7997.65 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 258 445 450.90 $22739.79 $50.43
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 15 18.00 $27000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 10 16.03 $801.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 3.52 $175.84 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 110 169 454.18 $22709.06 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 91 208.85 $10442.64 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 97 265.05 $13252.38 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 170 419.41 $20970.43 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.43 $571.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 29 29 284.34 $14216.90 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 3 50.43 $1260.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 467 5065.90 $253295.12 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 42.29 $2114.29 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 149 262 3045.97 $206760.52 $67.88
PHY -97110 PT SESSION BY LICENSED PT 153 314 3469.01 $235476.39 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 4.37 $237.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 4.61 $4.61 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 3 6.00 $112.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 14.43 $721.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 355 649 5702.00 $387051.78 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 21 252.50 $3333.00 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 386 953 851449.58 $425724.79 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 24.82 $1241.08 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 12 49.43 $2471.43 $50.00
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Subtotal (Total Children Is Unduplicated) 549 3285 870868.74 $1630584.36 $1.87
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Total 3732 871323.42 $1653427.22 $1.90
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Number of Children (Unduplicated) With at Least One Authorization 563