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: 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
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 4 4 4.00 $240.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 4.00 $500.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 3 5 5.00 $250.00 $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 46 58 59.00 $2861.50 $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 17 19 19.00 $921.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 9 9 9.00 $450.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 54 64 65.90 $3196.15 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 117 167 171.90 $8686.79 $50.53
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 4 4.60 $230.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.47 $23.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 69 84 128.65 $6432.27 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 39 45.82 $2290.83 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 44 70.15 $3507.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 84 118.43 $5921.25 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.43 $571.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 2 13.14 $328.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 207 1234.64 $61731.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 89 114 813.97 $55252.07 $67.88
PHY -97110 PT SESSION BY LICENSED PT 101 127 817.16 $55468.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.88 $47.98 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 4.61 $4.61 $1.00
SENS -V5264 EARMOLD 1 2 4.00 $74.88 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 12.00 $600.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 215 281 1486.79 $100923.62 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 27.57 $363.94 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 289 551 273682.07 $136841.03 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 21.86 $1092.86 $50.00
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Subtotal (Total Children Is Unduplicated) 344 1567 278518.37 $439964.08 $1.58
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Total 1735 278691.27 $448650.87 $1.61
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Number of Children (Unduplicated) With at Least One Authorization 349