Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 32 39.71 $1926.14 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.64 $38.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 128 139 214.14 $10707.14 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 235 292 302.82 $14686.95 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 202 246 281.93 $13673.77 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 275 337 359.22 $17422.35 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.50 $125.00 $50.00
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Subtotal (Total Children Is Unduplicated) 602 1054 1208.98 $59252.02 $49.01
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 14 16 36.44 $1821.90 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 193 278 532.07 $26603.58 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 82 119 194.28 $9714.06 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 91 140.93 $7046.45 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 125 168 302.41 $15120.48 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.50 $12.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 1.33 $97.48 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 86 123 843.16 $21078.92 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 680 942 6972.19 $348609.38 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 318 435 2318.09 $157351.81 $67.88
PHY -97110 PT SESSION BY LICENSED PT 318 435 2289.83 $155433.32 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 42 50 39.97 $39.97 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 4 4 10.02 $187.62 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 20 23 77.64 $3881.91 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 358 464 2240.54 $152087.82 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 3 9.93 $131.06 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 31.64 $3164.28 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 596 887 4564.71 $2282.36 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 10 61.75 $3087.50 $50.00
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Subtotal (Total Children Is Unduplicated) 954 4061 20672.41 $909817.37 $44.01
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Total 5116 21882.39 $969106.38 $44.29
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Number of Children (Unduplicated) With at Least One Authorization 992