Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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 11 12 12.00 $582.00 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.31 $71.30 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.02 $61.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 134 138 147.20 $17604.56 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 32 52.35 $2539.09 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 32.92 $1596.80 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 64 65 79.14 $3838.43 $48.50
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Subtotal (Total Children Is Unduplicated) 198 285 332.95 $26937.11 $80.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 22 23.00 $34500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 6.07 $418.08 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 40.88 $2043.81 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.83 $20.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 27 67.67 $3383.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 21.73 $543.16 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 19.90 $995.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 2 3.07 $76.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 17 35.62 $1780.88 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 14.14 $353.45 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 17 59.66 $2982.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 12.04 $301.08 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 99 104 221.34 $5533.47 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 417 508 3311.35 $165567.59 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 8.43 $421.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 52.68 $2633.82 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.71 $863.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 25 28 253.51 $13770.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 50.43 $3423.09 $67.88
PHY -97110HM PT SESSION BY PT ASST 34 41 377.74 $20519.02 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 35 36 37.73 $37.73 $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 4 4 3.16 $205.15 $65.00
SENS -V5264 EARMOLD 5 5 7.93 $148.51 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 20.93 $1046.44 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 25 30 317.57 $4191.95 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 481 895 4982.11 $266311.01 $53.45
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Total 1180 5315.06 $293248.12 $55.17
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Number of Children (Unduplicated) With at Least One Authorization 496