Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 37 37 1173.719048 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 37 1173.719048 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 6.622221 $321.1700 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 6.429908 $385.7900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.705556 $31.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 10.195236 $1172.4400 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.466667 $123.3400 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 2.450000 $118.8300 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.250000 $3.7500 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 0.027778 $1.3500 $48.5400
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Subtotal (Total Children Is Unduplicated) 28 33 29.147366 $2158.4100 $74.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 10.066667 $15100.0500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 6.303967 $315.2000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 16.288889 $814.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 7.644444 $191.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 347 526 1514.962746 $75748.3700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 8.033334 $200.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 193 197 513.015095 $25650.8300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 20.700001 $517.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 241 243 589.250016 $29462.5700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 5.733333 $143.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 305 310 782.900821 $39145.1800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 23.911112 $597.7800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 113.857143 $2846.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.695238 $834.7700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 24.142856 $1207.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 692 699 5426.950812 $271347.9200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 16.638096 $831.9100 $50.0000
INTR -INTR INTERPRETER 46 47 405.965078 $20298.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 16.571428 $1124.8700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $178.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 69 70 618.204761 $41963.7900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 45.714286 $2483.2000 $54.3200
SENS -FM FM RECEIVER HEARING AID 1 1 1.766667 $2915.0600 $1650.0300
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.161111 $580.5500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.500000 $97.5000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.250000 $28.5000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.133333 $258.3900 $227.9900
SENS -V5264 EARMOLD 7 7 6.630744 $119.3500 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 45.847620 $2292.3900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 51 435.638098 $29571.1300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.571429 $302.6400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 62.714286 $827.8300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 784 909 7153.350013 $3576.6700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 35.714285 $1785.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 811 3164 17938.113423 $573359.7200 $31.9600
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Total 3234 19140.979837 $575518.1300 $30.0700
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Number of Children (Unduplicated) With at Least One Authorization 845