Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 21 22 7.43 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 4.50 $166.50 $37.00
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Subtotal (Total Children Is Unduplicated) 23 29 11.93 $166.50 $13.95
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 6.00 $216.42 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 22 22.00 $1320.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 16 16 15.80 $1975.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 9.00 $1125.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 4 4 4.00 $120.00 $30.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 3.00 $225.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 83 89 89.00 $4316.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 100 114 114.00 $5529.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 255 283 294.04 $14261.16 $48.50
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Subtotal (Total Children Is Unduplicated) 351 555 566.84 $30155.68 $53.20
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 9.10 $455.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 377 471 907.06 $45353.12 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 36 41 83.15 $2078.74 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 16.16 $807.78 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 11.70 $585.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 361 448 859.16 $42957.75 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 34 37 82.25 $2056.24 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 19 19 186.58 $13698.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.29 $82.14 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 4.29 $107.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 425 536 4446.56 $222327.90 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 10.43 $521.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 83 96 458.93 $31152.08 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 19.50 $1059.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 107 127 689.57 $46808.13 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 14.29 $776.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 15 122.30 $6114.76 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 263 299 1471.30 $99871.54 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 20 20 99.86 $1318.11 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 3.03 $303.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 470 707 15364.17 $7682.08 $0.50
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Subtotal (Total Children Is Unduplicated) 566 2848 24863.64 $526116.93 $21.16
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Total 3432 25442.42 $556439.10 $21.87
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Number of Children (Unduplicated) With at Least One Authorization 581