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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 19 19 22.000000 $1067.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 14 15 31.352381 $1881.1500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 6.144445 $706.6200 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 4.000000 $500.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 18 20 39.000000 $4875.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 132 135 269.250000 $13462.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 16 32.000000 $2400.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 135 135 270.500000 $20287.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 58 58 116.000000 $8700.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 135 135 270.000000 $14985.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 171 187 374.500000 $28087.5000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.000000 $436.5000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 16 27.714286 $1344.1400 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 468 790 1536.461112 $102835.9100 $66.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 22 25.714286 $38571.4500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 15 16 23.346033 $1167.3100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 108 119 188.859523 $9442.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 67 81 195.919049 $9795.9700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 20 22 41.447620 $1036.1900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 8 17.004762 $850.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.066667 $76.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 54 112.723810 $5636.2000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 17 18 37.680954 $942.0300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 69 185.085718 $9254.3100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 17 20 50.742858 $1268.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 27 275.285713 $6882.1500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.714286 $585.7200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 17.380952 $869.0500 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 49.714285 $1242.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 971 1213 9246.485725 $462324.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 48.285714 $2414.2900 $50.0000
INTR -INTR INTERPRETER 87 149 732.669045 $36633.4700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 21 185.571429 $12596.6000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 124 164 1378.547621 $93575.9100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 8 81.999999 $4454.2500 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 108 117 140.925396 $140.9300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.000000 $2000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 5.955556 $387.1100 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5264 EARMOLD 7 7 13.100000 $235.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 15 17 122.071428 $6103.5900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 227 1759.519050 $119436.2100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 53.428571 $705.2600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1154 1883 13334.347632 $6667.1700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 54.857144 $2742.8600 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1280 4303 28401.450826 $838228.8200 $29.5100
-------------------------------------------------------------------------------------------------------------------------------------
Total 5093 29937.911938 $941064.7300 $31.4300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1327