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
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Subtotal (Total Children Is Unduplicated) 1 1 0.250000 $9.2500 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.000000 $460.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
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 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.000000 $194.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 33 34 35.900000 $2209.0000 $61.5300
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 15 17 56.780953 $2839.0500 $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 9 10 14.019048 $350.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 16.466666 $823.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.000000 $50.0000 $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 70 84.272145 $4213.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 19.140477 $478.5100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 2.877778 $211.0000 $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 9 9 51.428573 $1285.7200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 26.285714 $1314.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 24 35 161.866666 $8093.3400 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 29.714285 $2017.0100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 3 3.947620 $267.9700 $67.8800
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
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.088889 $204.4500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 29.419047 $1996.9600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 26.285714 $346.9700 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.285714 $514.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 210 344 748.535192 $34257.4300 $45.7700
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Total 379 784.685192 $36475.6800 $46.4800
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Number of Children (Unduplicated) With at Least One Authorization 218