Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 8 8 8.000000 $532.5000 $66.5600
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.857143 $142.8600 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 86 92 43.572225 $2178.6300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.475000 $11.8800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 37 282.955162 $14147.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.050000 $1.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 44 24.103572 $1205.1900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.050000 $1.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 61 34.355163 $1717.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.983334 $49.5900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 14.857143 $742.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 90 90 611.428573 $30571.4700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 42 257.614285 $17486.8500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $85.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 46 47 240.030950 $16293.3200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 6.035714 $327.8600 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.000000 $500.0000 $500.0000
SENS -V5264 EARMOLD 1 1 0.444444 $8.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 5.714286 $285.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 62 454.740475 $30867.7900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.857143 $50.9100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 127 206 28866.941261 $14433.4700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 11.142857 $557.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 138 699 30865.780159 $131666.9200 $4.2700
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Total 707 30873.780159 $132199.4200 $4.2800
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Number of Children (Unduplicated) With at Least One Authorization 139