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: 01/01/09 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
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 7 10.00 $1250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 6 7 7.00 $350.00 $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 48 60 60.00 $2910.00 $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 23 27 27.00 $1309.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 10 11 11.00 $550.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 73 87 87.23 $4230.82 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 139 205 209.23 $10917.96 $52.18
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 6 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 7.00 $350.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 84 104 176.54 $8826.79 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 52 80.19 $4009.69 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 58 98.67 $4933.45 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 110 156.03 $7801.67 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 12.86 $642.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.86 $321.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 151 212 1293.85 $64692.49 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 3 21.86 $1092.86 $50.00
INTR -INTR INTERPRETER 1 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 78 108 844.63 $57333.58 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 16.93 $919.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 95 141 816.58 $55429.11 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.43 $294.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 2.82 $2.82 $1.00
SENS -V5264 EARMOLD 1 2 4.00 $74.88 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 3.29 $164.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 213 305 1679.64 $114013.86 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.21 $95.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 288 600 291690.93 $145845.47 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 10 25.43 $1271.43 $50.00
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Subtotal (Total Children Is Unduplicated) 338 1731 296972.74 $479066.32 $1.61
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Total 1936 297181.97 $489984.27 $1.65
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Number of Children (Unduplicated) With at Least One Authorization 345