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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 32 45 58.14 $2819.93 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 2 2.04 $122.66 $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 64 68 94.86 $4742.86 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 5 5.14 $257.15 $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 273 372 388.38 $18836.47 $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 253 342 368.57 $17875.71 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 342 452 516.71 $25060.64 $48.50
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Subtotal (Total Children Is Unduplicated) 661 1292 1441.85 $70384.43 $48.82
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 26.80 $1340.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 101 122 198.09 $9904.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 4.87 $121.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 46 60.06 $3002.78 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 37 42.33 $2116.66 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 79 115.76 $5788.24 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.19 $79.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 105 173 856.64 $21416.11 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 765 1130 7698.91 $384945.36 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 377 580 3085.79 $209463.37 $67.88
PHY -97110 PT SESSION BY LICENSED PT 367 563 3002.40 $203802.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.86 $318.16 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 36 44 40.07 $40.07 $1.00
SENS -V5264 EARMOLD 2 2 2.98 $55.74 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 20 31 59.39 $2969.52 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 468 666 3312.09 $224824.45 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.07 $14.14 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.43 $942.86 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 674 1039 6192.72 $3096.35 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 28 116.26 $5812.88 $50.00
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Subtotal (Total Children Is Unduplicated) 1040 4559 24835.70 $1081555.45 $43.55
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Total 5851 26277.55 $1151939.88 $43.84
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Number of Children (Unduplicated) With at Least One Authorization 1071