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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 1.011111 $37.4100 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 3 2.011111 $74.4100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 11 11.000000 $533.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 67 75 92.766667 $5566.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 10 9.600000 $432.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 40 43 52.022222 $5982.5500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 8.285715 $1035.7100 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 36 37 61.500000 $3075.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 6 7.000000 $525.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 28 28 53.000000 $3975.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 38 68.000000 $3774.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 11.142857 $540.4300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.000000 $485.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.000000 $194.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 181 272 389.317461 $26168.2000 $67.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 24 31.000000 $46500.0000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 16 21 110.382538 $5519.1300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.011111 $25.2800 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 41 51 100.269840 $5013.5000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 8.300000 $207.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 49 108.385715 $5419.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.133333 $28.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 101 185.397619 $9269.8800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.800000 $145.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 79 163.052380 $8152.6300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 10.511111 $262.7800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 17 59.195237 $4340.1900 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 11.571429 $289.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 33 115.876190 $2896.9100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 405 596 3578.253958 $178912.6900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 16 36.306348 $1815.3100 $50.0000
INTR -INTR INTERPRETER 2 3 7.044445 $352.2300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 21 127.914286 $8682.8200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.428571 $240.5600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 26 33 244.695235 $16609.9200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 12 113.076190 $6142.2900 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 22 15.266666 $15.2700 $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 8 8 8.208219 $533.5300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 9 13 31.011110 $558.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 18 37.071427 $1853.5600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 27 114.700000 $7785.8500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 7 57.000000 $752.4000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 301 673 145074.100000 $72537.0500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.285714 $164.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 450 1856 150373.248672 $386807.0800 $2.5700
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Total 2131 150764.577244 $413049.6900 $2.7400
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Number of Children (Unduplicated) With at Least One Authorization 453