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
EXIT -EXIT TRANSITION ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 9 9 9.000000 $444.0000 $49.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.000000 $3000.0000 $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 66 87 136.233336 $6811.6800 $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
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.000000 $50.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 3 17.000000 $850.0000 $50.0000
INTR -INTR INTERPRETER 12 15 87.795239 $4389.7700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.714286 $252.1300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 2 13.607143 $923.6500 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 6.033333 $6.0300 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 9 42.964285 $2916.4200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 269 547 225858.109525 $112929.0500 $0.5000
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Subtotal (Total Children Is Unduplicated) 284 1122 226953.185741 $171288.5900 $0.7500
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Total 1131 226962.185741 $171732.5900 $0.7600
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Number of Children (Unduplicated) With at Least One Authorization 285