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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 98 113 119.00 $5771.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.01 $60.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 41 42 42.00 $2100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 318 380 434.71 $21083.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 229 274 295.00 $14307.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 372 450 514.86 $24970.57 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 717 1262 1408.58 $68460.27 $48.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 16 17 18.01 $900.56 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 17 11.86 $592.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.01 $25.28 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 9 6.38 $319.17 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.47 $123.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 11 6.84 $342.22 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 112 146 1085.29 $27132.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 845 1149 8432.90 $421644.93 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 457 589 3759.60 $255201.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.36 $453.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 396 527 3343.37 $226948.18 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 39 47 43.37 $43.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 2.02 $37.86 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 24 28 68.02 $3401.14 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 527 677 4019.10 $272816.62 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.00 $198.00 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 35.14 $3514.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 805 1265 7793.51 $3896.75 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 23 58.74 $2937.14 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1148 4521 28716.00 $1223129.59 $42.59
-----------------------------------------------------------------------------------------------------------------------------
Total 5783 30124.58 $1291589.87 $42.87
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1187