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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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 4 4 1.688890 $62.4900 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.000000 $74.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 3.688890 $136.4900 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.511111 $412.7900 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $21.7300 $21.7300
AUDE -AUDE UNSPECIFIED AUDE SERVICES 84 92 87.430157 $5245.8000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 11 9.194445 $413.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 32 34 40.373645 $4642.9500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 53 55 61.190762 $3059.5500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 7.600000 $570.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 27 46.944444 $3520.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 35 36 57.766666 $3206.0500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 0.033333 $1.8500 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 0.033333 $2.5000 $74.9300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 14.142857 $685.9300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 5.033334 $244.1200 $48.5000
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Subtotal (Total Children Is Unduplicated) 187 292 344.265198 $22424.1700 $65.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 15 20.095541 $30143.2500 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 3.022222 $208.1100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.105556 $7.2700 $68.8900
AUD -HA_FUP AUDIOLOGY SERVICES 20 22 125.509525 $6275.4800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 19 3.745438 $187.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.644444 $16.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 118 499 875.725224 $43786.3400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 3.430555 $85.7600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 69 154.223012 $7711.1500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 82 168.555560 $8427.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.866667 $71.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 97 191.692059 $9584.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 14 16.411111 $410.2800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 22 82.880953 $6076.8300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 31 85.985712 $2149.6400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 382 608 3429.786502 $171489.4600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 13 13 48.811112 $2440.5600 $50.0000
INTR -INTR INTERPRETER 2 2 5.266667 $263.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 19 108.695239 $7378.2400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 19.857143 $1078.6400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 22 27 174.419048 $11839.5700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 15 17 126.000000 $6844.3300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 13.277781 $13.2800 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 6.571429 $10842.8100 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.255556 $1127.8000 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 9 10.511111 $683.2200 $65.0000
SENS -V5264 EARMOLD 11 12 23.144443 $416.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 21 72.107937 $3605.4000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 22 115.328571 $7828.5300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 37.885715 $500.0900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 387 1297 268497.314849 $134248.6600 $0.5000
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Subtotal (Total Children Is Unduplicated) 433 2965 274426.126682 $475742.0500 $1.7300
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Total 3262 274774.080770 $498302.7100 $1.8100
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Number of Children (Unduplicated) With at Least One Authorization 434