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: 04/01/10 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.84 $31.24 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.84 $31.24 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 30 31 43.00 $2580.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 18 18.00 $2152.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 132 144 147.30 $7144.05 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 173 195 195.00 $9457.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 410 458 520.32 $25235.70 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.00 $1100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 553 850 937.62 $48045.05 $51.24
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 243 253 398.28 $19913.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 48 49 52.61 $1315.31 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 20 33.08 $1654.18 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.53 $63.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 18 27.15 $1357.40 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.83 $170.85 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 471 547 621.70 $31085.21 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 47 49 37.85 $946.34 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 24.00 $1762.08 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 26 247.29 $6182.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 566 676 5820.05 $291002.68 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 130 150 864.75 $58699.26 $67.88
OCCT -97530HM OT SESSION BY OT ASST 26 27 160.43 $8714.49 $54.32
PHY -97110 PT SESSION BY LICENSED PT 168 189 1123.00 $76229.27 $67.88
PHY -97110HM PT SESSION BY PT ASST 23 23 123.90 $6730.51 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 8.80 $8.80 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 43.16 $2158.02 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 456 524 3025.32 $205358.92 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 15 16 71.64 $945.68 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.71 $71.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 597 792 7192.94 $3596.47 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.00 $500.00 $50.00
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Subtotal (Total Children Is Unduplicated) 816 3397 19902.05 $723116.14 $36.33
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Total 4248 20840.51 $771192.44 $37.00
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Number of Children (Unduplicated) With at Least One Authorization 828