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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 40 44 32.446030 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.366667 $17.7900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 9 2.427779 $117.7500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.172222 $8.3500 $48.4900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.105556 $5.1200 $48.5200
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 8.584126 $416.3300 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 20 23 11.686487 $566.8500 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.191781 $287.7000 $1500.1500
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 13.476985 $673.8500 $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 4 4 20.000000 $1000.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 24 152.071431 $10322.6100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 3 13.714286 $744.9600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 14 18 136.392855 $9258.3600 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 3 0.504110 $32.7700 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 68 530.750001 $36027.3400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 362 653 294878.452733 $147439.2200 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 369 1057 296115.548415 $217137.1900 $0.7300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1124 296159.680932 $217704.0300 $0.7400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 404