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: 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 14 15 13.644445 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 1.888889 $69.8900 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 18 15.533334 $69.8900 $4.5000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.033333 $292.6200 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 59 65 56.930741 $3415.8200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 10 7.866666 $354.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 19 21 21.019515 $2417.2500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT EXIT ASSESSMENT 37 37 43.633646 $2181.6800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 3.389345 $254.2000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 17 17 26.261948 $1969.6400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 0.044444 $3.3300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 25 25 30.717959 $1704.8400 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.285714 $62.3600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 7.961111 $386.1100 $48.5000
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Subtotal (Total Children Is Unduplicated) 130 198 206.144422 $13166.8400 $63.8700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 10.457523 $15686.1000 $1499.9800
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.144444 $78.8000 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.238889 $16.4500 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 18 19 104.884127 $5244.2100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 15 4.677781 $233.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 117 558 1258.396106 $62920.1700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 4.372222 $109.3100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 42 113.188893 $5659.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 48 117.504767 $5875.2600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.733334 $168.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 68 152.896039 $7644.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 9.044445 $226.1100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 13 45.076190 $3304.9900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 19 21 77.323813 $1933.1000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 312 406 2751.035966 $137551.9100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 13 38.406351 $1920.3300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 21.752380 $1476.5600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 2 13.142857 $713.9200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 16 17 145.638094 $9885.9400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 13 106.142857 $5765.6900 $54.3200
SENS -FM FM RECEIVER HEARING AID 1 1 13.142857 $21685.7900 $1650.0100
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.155556 $400.1100 $65.0000
SENS -V5264 EARMOLD 9 10 17.077778 $307.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 14 32.166668 $1608.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 12 81.490477 $5531.5800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 22.990476 $303.4700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 329 1001 268409.534881 $134204.7700 $0.5000
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Subtotal (Total Children Is Unduplicated) 349 2317 273565.132438 $430712.5200 $1.5700
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Total 2533 273786.810194 $443949.2500 $1.6200
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Number of Children (Unduplicated) With at Least One Authorization 357