Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.044444 $1.6400 $36.9600
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Subtotal (Total Children Is Unduplicated) 1 1 0.044444 $1.6400 $36.9600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.000000 $120.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 16 16 20.000000 $1000.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 32 38 42.000000 $2354.0000 $56.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.000000 $6000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 18 19 108.063491 $5403.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.500000 $125.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.377778 $9.4500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 54 68 132.211903 $6610.5900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 13 15 16.400000 $410.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 32 52.733333 $2636.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 2.555556 $63.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 85 100 112.535715 $5626.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 9 7.900000 $197.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 94 123.239465 $6161.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 12 8.044444 $201.1100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.222222 $16.2900 $73.3100
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 13.000000 $325.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 26.209524 $655.2400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 28.428571 $1421.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 26 121.652382 $6082.6200 $50.0000
INTR -INTR INTERPRETER 1 2 3.755556 $187.7800 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 3 6.071429 $412.1300 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 22 18.349205 $18.3500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.249315 $406.2000 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 14.495238 $983.9400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 147 267 34949.431737 $17474.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 311 696 35760.426864 $62429.8200 $1.7500
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Total 735 35802.471308 $64785.4700 $1.8100
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Number of Children (Unduplicated) With at Least One Authorization 313