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
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Subtotal (Total Children Is Unduplicated) 4 4 1.688890 $62.4900 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.511111 $412.7900 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 1.449999 $86.9900 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.126027 $129.4900 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 53 55 61.190762 $3059.5500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.144444 $10.8300 $74.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.144444 $8.0100 $55.4800
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Subtotal (Total Children Is Unduplicated) 67 71 72.566787 $3707.6600 $51.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 6.870471 $10305.6000 $1499.9800
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 1 1 6.133333 $449.6900 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 17 85.057938 $4252.9000 $50.0000
INTR -INTR INTERPRETER 2 2 5.266667 $263.3400 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 23.857143 $1619.4300 $67.8800
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
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.714286 $141.4300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 387 1296 268397.314849 $134198.6600 $0.5000
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Subtotal (Total Children Is Unduplicated) 408 2173 270110.634159 $240454.5700 $0.8900
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Total 2248 270184.889836 $244224.7200 $0.9000
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Number of Children (Unduplicated) With at Least One Authorization 408