Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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 19 19 15.422223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 15.422223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 11.994444 $581.7300 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 1.800000 $87.3000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.811111 $87.8400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 0.305556 $14.8200 $48.5100
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Subtotal (Total Children Is Unduplicated) 37 40 15.911111 $771.6900 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.511111 $766.6500 $1499.9700
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 8.656349 $432.8200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 4.838889 $241.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 41 35.714283 $1785.7000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 48 40.077775 $2003.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 31 23.284123 $1164.1900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 54 59 458.142855 $22907.1800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 61.357142 $4164.9300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 8 9 62.665079 $4253.7100 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.888889 $57.7800 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 14.615080 $730.7500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 5.142857 $349.0900 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.428572 $2242.8500 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 988 1482 15344.541214 $7672.2600 $0.5000
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Subtotal (Total Children Is Unduplicated) 1002 1696 16082.864218 $48773.7200 $3.0300
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Total 1755 16114.197552 $49545.4100 $3.0700
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Number of Children (Unduplicated) With at Least One Authorization 1029