Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 22 23 29.182541 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 22 23 29.182541 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.016667 $194.8100 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 0.705556 $40.1800 $56.9400
AUDE -AUDE UNSPECIFIED AUDE SERVICES 26 26 22.217273 $1333.0200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.066667 $237.6700 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 36 43 48.357967 $2417.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.712699 $353.4500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 1.950000 $108.2300 $55.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.577778 $28.0200 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.140944 $394.8400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.511111 $24.7900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 3.574352 $173.3500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 15.050000 $729.9300 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.046575 $2.3300 $50.0300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 102 123 113.927589 $6133.5000 $53.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.511111 $766.6500 $1499.9700
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.433333 $29.8400 $68.8500
AUD -HA_FUP AUDIOLOGY SERVICES 21 21 23.306891 $1165.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 26 50.901589 $2545.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 200 882 1094.569207 $54728.2800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 0.777778 $19.4500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 48 112.728578 $5636.4600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.000000 $75.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 57 145.930163 $7296.5100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.022222 $25.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 120 124 182.769049 $9138.4600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.360318 $109.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.066667 $51.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 4.428571 $221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 392 442 3932.719062 $196636.1400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 19 21 102.863497 $5143.1700 $50.0000
INTR -INTR INTERPRETER 11 13 106.714285 $5335.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 29 263.923808 $17915.1800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 13.142857 $713.9200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 47 50 533.938093 $36243.7600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 39.428571 $2141.7700 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.066667 $1033.3500 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.504110 $32.7700 $65.0000
SENS -V5264 EARMOLD 11 11 19.188885 $345.3900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 57 495.611111 $33642.1200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 11.285714 $613.0400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 13.142857 $173.4900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 482 1423 497529.815908 $248764.8900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 22.000000 $1100.0000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 7 59.000001 $2950.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 489 3234 504772.156459 $634593.5400 $1.2600
-------------------------------------------------------------------------------------------------------------------------------------
Total 3380 504915.266589 $640727.0500 $1.2700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 509