Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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 -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.877777 $292.6600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.000000 $135.0000 $45.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 47 54.428571 $2639.7900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 32 32.000000 $1552.0000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 25 27 27.000000 $1350.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 75 93 93.000000 $4510.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 129 210 219.306348 $10803.4500 $49.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 9 12.000000 $18000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 4.066667 $203.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.900000 $145.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 120 172 283.957147 $14197.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 89 139.700003 $6985.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 95 174.271436 $8713.6100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.066667 $76.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 175 316.466677 $15823.3900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 7 43.428570 $1085.7200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 8 11.928571 $596.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 4.428571 $221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 130 199 835.980953 $41799.0900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 15 107.642856 $5382.1600 $50.0000
INTR -INTR INTERPRETER 12 15 87.795239 $4389.7700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 71 517.292855 $35113.8500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 78 115 737.590476 $50067.6300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 6 57.857142 $3142.8000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 11 6.633333 $6.6300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -V5264 EARMOLD 2 2 5.755556 $103.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 18.714286 $935.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 172 247 1206.587689 $81903.2600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.285714 $178.4800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 42.249999 $557.7000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 272 551 229123.823811 $114561.9100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 7 26.469047 $1323.4500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 20.500001 $1025.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 301 1815 233796.393266 $407539.4900 $1.7400
-------------------------------------------------------------------------------------------------------------------------------------
Total 2025 234015.699614 $418342.9400 $1.7900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 309