Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 1 1 2.733333 $164.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.022222 $577.5500 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 17 18 21.571429 $1046.2100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 40 43 43.000000 $2085.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 12 12.000000 $582.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 20 18.766667 $910.1900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 60 68 69.210317 $3356.6900 $48.5000
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Subtotal (Total Children Is Unduplicated) 109 169 176.303968 $8902.1400 $50.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 6.000000 $9000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 8.844445 $442.2300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.022222 $201.1100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 7 15.466668 $386.6700 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 37 29.153967 $1457.7000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 38 42 95.609529 $2390.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 13.316666 $665.8300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 14 30.833335 $770.8400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 8.138890 $406.9500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 17 18 37.400001 $935.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 28 28.703967 $1435.2000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 25 27 59.466670 $1486.6800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 85 805.428566 $40271.4900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 7 54.571429 $2728.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 111 140 1072.600001 $72808.1800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 27.714285 $1505.4500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 57 73 473.095242 $32113.7100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 13 15 81.071429 $4403.8000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 31 37.836509 $37.8400 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 4 4 4.688888 $84.4000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 10.285714 $514.2900 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 216 265 1946.669042 $132140.0600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 42.000000 $554.4000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 319 484 4885.619817 $2442.8000 $0.5000
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Subtotal (Total Children Is Unduplicated) 375 1334 9784.537282 $310210.4200 $31.7000
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Total 1503 9960.841250 $319112.5700 $32.0400
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Number of Children (Unduplicated) With at Least One Authorization 376