Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 2.26 $135.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 42 43 80.00 $4000.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 15 15 30.00 $1665.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 72 73 146.00 $10950.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 17 18 36.00 $2700.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 45 47 94.00 $7050.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 83 83 166.00 $9213.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 16.00 $1200.00 $75.00
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 32 34 35.00 $1697.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 40 43 44.00 $2134.00 $48.50
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Subtotal (Total Children Is Unduplicated) 202 384 672.26 $42175.14 $62.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 32 40.00 $60000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 8.07 $403.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 281 731 1464.07 $73203.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 289 365 732.13 $36606.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 132 170 338.00 $16900.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 175 233 469.07 $23453.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 242 306 615.20 $30760.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.00 $100.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 3.70 $92.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 38 44 157.37 $3934.37 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 16 112.86 $5642.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 255 316 2250.41 $112520.66 $50.00
INTR -INTR INTERPRETER 7 10 30.00 $1500.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 72 87 478.55 $32483.63 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $58.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 123 161 807.00 $54779.31 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 7.50 $407.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 12 13.40 $13.40 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.25 $16.20 $65.00
SENS -V5264 EARMOLD 1 1 1.91 $35.78 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 209 1125.35 $76388.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 7 67.29 $888.17 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 15.00 $1500.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 330 515 3387.28 $1693.64 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.86 $42.86 $50.00
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Subtotal (Total Children Is Unduplicated) 346 3231 12133.83 $533986.79 $44.01
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Total 3615 12806.08 $576161.93 $44.99
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Number of Children (Unduplicated) With at Least One Authorization 355