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 13 13 16.000000 $776.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 126 128 255.250000 $12762.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 21 42.000000 $3150.0000 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 166 190 367.250000 $20407.0000 $55.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 18.033334 $901.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 105 115 183.359523 $9167.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 66 80 192.852382 $9642.6300 $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 47 53 111.723810 $5586.2000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 17 36.647621 $916.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 67 176.876194 $8843.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 16 19 48.209525 $1205.2400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 13.142857 $328.5700 $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 3 3 13.666666 $683.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 49 347.538098 $17376.9300 $50.0000
INTR -INTR INTERPRETER 86 148 721.240474 $36062.0400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 20.714286 $1406.0900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 9 10 69.180953 $4696.0100 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 103 111 134.925396 $134.9300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 11 90.714286 $6157.6900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1141 1852 13069.123822 $6534.5600 $0.5000
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Subtotal (Total Children Is Unduplicated) 1232 2589 15327.182562 $114767.6700 $7.4900
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Total 2779 15694.432562 $135174.6700 $8.6100
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Number of Children (Unduplicated) With at Least One Authorization 1241