Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 40 44 32.446030 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 44 32.446030 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.449315 $20.2200 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 6.042313 $694.8500 $115.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 21 8.467460 $410.6700 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 38 24.293336 $1178.2200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 12 12.810317 $621.2900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 29 31 6.047107 $293.2800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 82 90 31.389058 $1522.3400 $48.5000
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Subtotal (Total Children Is Unduplicated) 146 202 89.529043 $4742.3800 $52.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 0.649163 $973.8000 $1500.0900
AUD -HA_FUP AUDIOLOGY SERVICES 6 8 15.455067 $772.7600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 3.961797 $198.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 6 8.205481 $205.1400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 42 48 24.349923 $1217.4900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 56 64 128.616672 $3215.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 24 29.138138 $1456.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 17 26 38.966666 $974.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 14 8.538888 $426.9400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 19 35.433334 $885.8400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 30 18.033331 $901.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 34 37 74.750003 $1868.7600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 79 92 799.347622 $39967.4100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 7 39.927354 $1996.3700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 98 122 901.135716 $61169.1100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 9 10 38.928573 $2114.6000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 63 84 658.347617 $44688.6800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 13 20 78.571429 $4268.0000 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 4 0.652055 $42.3800 $64.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 0.701370 $159.9000 $227.9800
SENS -V5264 EARMOLD 4 5 6.533332 $117.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 6 47.142858 $2357.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 244 298 2264.723819 $153729.5400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.000000 $380.2400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 40.714286 $537.4300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 362 653 294878.452733 $147439.2200 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 13.230528 $661.5300 $50.0000
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Subtotal (Total Children Is Unduplicated) 386 1602 300161.507755 $472726.0800 $1.5700
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Total 1848 300283.482828 $477468.4700 $1.5900
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Number of Children (Unduplicated) With at Least One Authorization 422