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 1 1 2.733333 $164.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.911111 $104.7800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.466667 $123.3400 $50.0000
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Subtotal (Total Children Is Unduplicated) 13 15 13.188888 $733.7800 $55.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 6.933334 $10400.1000 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 6.053967 $302.7000 $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 346 525 1514.677032 $75734.0900 $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 1 1 9.285714 $232.1400 $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 66 66 540.476192 $27023.8400 $50.0000
INTR -INTR INTERPRETER 46 47 405.965078 $20298.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.428571 $232.7300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $178.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 8.857143 $601.2200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 15.571429 $845.8400 $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 1 1 0.911111 $455.5500 $499.9900
SENS -V5264 EARMOLD 1 1 1.822222 $32.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 21.714286 $1473.9700 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 781 905 7135.569059 $3567.7800 $0.5000
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Subtotal (Total Children Is Unduplicated) 795 2356 11684.632658 $243060.0700 $20.8000
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Total 2408 12871.540594 $243793.8600 $18.9400
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Number of Children (Unduplicated) With at Least One Authorization 829