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: 07-01-11 and 09-30-11 Date of Report: 11-30-11 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 0.250000 $9.2500 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.428571 $126.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.678571 $136.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.800000 $70.3400 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 42 42 43.244444 $2594.6600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 10.733333 $483.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 65 67 67.066666 $7712.6600 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 11 15.133334 $1891.6800 $125.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 7 7.000000 $525.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 33 33 47.285714 $2624.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.000000 $75.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 7 7 7.900000 $395.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 23.000000 $1115.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 26 26.000000 $1261.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 73 75 75.000000 $3637.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 220 316 337.163491 $23048.7000 $68.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 14 39.571429 $59357.1000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.400000 $165.2600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 16 19 58.780953 $2939.0500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 47 50 78.285715 $3914.3000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 10 11 15.019048 $375.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 16.466666 $823.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 67 90.028572 $4501.4400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 9 9.000000 $225.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 71 85.272145 $4263.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 19.140477 $478.5100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 15 23 64.544446 $4732.4000 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.285714 $107.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 66 76 286.419050 $7160.4800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 26.285714 $1314.2900 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.285714 $407.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 421 618 3582.528566 $179126.6100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 14 44.114284 $2205.7200 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 32 191.671427 $13010.6600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 10 15 112.714286 $6122.6500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 49 62 559.195236 $37958.2300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 25 29 152.776190 $8298.8100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 27 19.938094 $19.9400 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 5.117808 $332.6600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 16 19 23.600000 $424.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 23 26 73.850795 $3692.5400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 46 292.838094 $19877.8500 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.428571 $240.5600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 34 36 255.128570 $3367.7000 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.285714 $564.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 475 1308 6150.973278 $367144.5100 $59.6900
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Total 1628 6491.815340 $390329.3200 $60.1300
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Number of Children (Unduplicated) With at Least One Authorization 479