Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $230.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7 9 14.000000 $1034.5000 $73.8900
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 3.000000 $150.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 12 12.666667 $633.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 128 174 194.576190 $9728.8100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 14 21 22.400000 $560.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 33 47.133334 $2356.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 7 8.366667 $209.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 34 34.000000 $1700.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 69 76.771429 $3838.5700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 15 19 19.600000 $490.0000 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.066667 $76.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 13 117.428571 $5871.4400 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 13.142857 $892.1400 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 92 105 102.844445 $102.8400 $1.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 84.999999 $5769.8100 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 63 68 7579.723810 $3789.8600 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 309 575 8330.720636 $36936.3100 $4.4300
-------------------------------------------------------------------------------------------------------------------------------------
Total 584 8344.720636 $37970.8100 $4.5500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 309