Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 36.00 $1332.00 $37.00
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Subtotal (Total Children Is Unduplicated) 5 5 36.25 $1341.25 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 10 12.00 $582.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 43 44 49.14 $2948.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 16.00 $1913.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.25 $62.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 69 74 145.00 $7250.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 41 74.50 $5587.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 14.00 $1050.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 15.00 $1125.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 39 39 73.00 $5475.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 42.00 $2331.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 366 414 777.71 $58328.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 63 120.50 $9037.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 87 96 176.50 $13237.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 339 390 732.21 $40637.63 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 215 240 441.00 $33075.00 $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 5 5 5.00 $242.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 9.00 $436.50 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 20.43 $990.79 $48.50
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Subtotal (Total Children Is Unduplicated) 646 1500 2732.24 $184660.21 $67.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 17 21.00 $31500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 7 8 29.29 $1464.28 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 66 73 108.89 $5444.65 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 11 15.59 $389.82 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 28 42.90 $2144.76 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 18 24 42.00 $1050.12 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 9 12.17 $608.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 8 12.25 $306.37 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 19 25.13 $1256.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 13 16.80 $420.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 37 71.82 $3590.95 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 23 27 56.06 $1401.55 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 37 43 290.21 $7255.35 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 52.57 $1314.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 787 975 7360.50 $368024.89 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 6 41.71 $2085.71 $50.00
INTR -INTR INTERPRETER 104 153 859.48 $42974.05 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 55 67 515.29 $34977.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.57 $248.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 174 213 1788.07 $121374.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 76.86 $4174.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 105 122 138.29 $138.29 $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 3 3 4.00 $260.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 7 8 15.74 $294.65 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 33.00 $1650.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 339 415 3640.40 $247110.59 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 22 22 199.32 $2631.04 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 5.14 $514.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1046 1681 12976.91 $6488.47 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1191 4009 28463.98 $892943.87 $31.37
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Total 5514 31232.47 $1078945.34 $34.55
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Number of Children (Unduplicated) With at Least One Authorization 1419