Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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 2 2 3.725397 $137.8400 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 8 6.634920 $245.4900 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 8 10 10.360317 $383.3300 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 87 101 101.012703 $4899.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 3.022222 $118.1100 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 70 71 71.000000 $842.0600 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 6 6.000000 $91.5000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 76 78 77.844444 $644.5500 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 76 78 78.655555 $816.4400 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 77 79 79.655555 $1679.1400 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 9 9 8.505556 $440.2500 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 67 68 69.533333 $1890.6100 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 235 253 245.988894 $14759.3600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 26 30 38.498413 $1732.4300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 70 76 91.379366 $10508.6300 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 14 14 42.585715 $5323.2100 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 36 45 31.844445 $1592.2300 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 344 369 676.676190 $33833.8100 $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 47 48 91.500000 $6862.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 15 30.000000 $2250.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 60 62 106.536111 $5912.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 257 257 503.511111 $37763.3300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 58 58 101.050000 $7578.7500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 241 241 403.358329 $22386.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 157 188 370.066667 $27755.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 23 23 24.437300 $1185.1900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 402 456 464.474611 $22527.0600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 14 8.133334 $394.4700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 389 451 438.876994 $21285.5900 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 62 66 90.955557 $4547.7900 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 3 1.866667 $28.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 469 528 557.395244 $27033.7000 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.000000 $200.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 13.000000 $650.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2340 3723 4875.364316 $270981.9700 $55.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 96 105 209.610317 $314415.3000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 107 121 299.051584 $14952.5800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 689 1030 2067.875611 $103394.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 34 36 47.152183 $1178.8000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2534 3323 7671.839639 $383591.6700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 115 129 239.052766 $5976.2900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1502 1720 3013.744443 $150687.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 36 38 69.787694 $1744.6800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1695 1978 4088.109116 $204405.3600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 49 53 80.344838 $2008.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3059 3750 6454.157897 $322707.6500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 114 123 207.659518 $5191.4800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 17 59.195237 $4340.1900 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 4 5 938.000000 $11725.0000 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 23.704762 $592.6200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 250 341 2911.204757 $72780.1200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 8 170.723810 $8536.2000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 16 174.680951 $8734.0400 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 11.114286 $277.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6612 8723 64637.519802 $3231875.4100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 19.500000 $975.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 71 90 430.851190 $21542.5500 $50.0000
INTR -INTR INTERPRETER 237 333 2204.628582 $110231.4100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1271 1658 10765.515075 $730763.1700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 48 52 363.165478 $19727.1400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1807 2393 15035.771848 $1020628.1600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 69 72 430.658331 $23393.3900 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 584 672 4659.646808 $4659.6500 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 1.333333 $2199.9500 $1649.9600
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 9 11 17.933334 $8966.7000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 13 14 13.657534 $887.7400 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 3 1.866667 $212.8000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 10 13.485236 $3074.6300 $228.0000
SENS -V5264 EARMOLD 60 69 103.335710 $1860.0400 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 6.800000 $340.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 102 130 339.396029 $16969.7900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2313 2969 19280.869045 $1308785.4000 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 22.428572 $1218.3200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 51 57 342.887297 $4526.1100 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 7 7 56.461905 $5646.1900 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6319 11350 3045047.173742 $1522523.6000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 8 9 41.623810 $2081.2000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 83 102 590.410320 $29520.5100 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9914 41536 3193167.929057 $9690123.9200 $3.0300
-------------------------------------------------------------------------------------------------------------------------------------
Total 45269 3198053.653690 $9961489.2200 $3.1100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 10098