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
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Subtotal (Total Children Is Unduplicated) 1 1 1.011111 $37.4100 $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 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 36 37 61.500000 $3075.0000 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 49 53 77.500000 $4007.0000 $51.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 7.000000 $10500.0000 $1500.0000
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
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 2 2 10.066667 $251.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 16 92.861904 $4643.1000 $50.0000
INTR -INTR INTERPRETER 2 3 7.044445 $352.2300 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 4 13.999999 $950.3200 $67.8800
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
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.133333 $212.6900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.714286 $115.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 301 673 145074.100000 $72537.0500 $0.5000
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Subtotal (Total Children Is Unduplicated) 368 1061 145949.210595 $125493.4600 $0.8600
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Total 1115 146027.721706 $129537.8700 $0.8900
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Number of Children (Unduplicated) With at Least One Authorization 368