Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 8 8 17.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 17.733333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 21 5.511111 $267.2900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.405556 $19.6700 $48.5100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.333333 $16.1700 $48.5000
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Subtotal (Total Children Is Unduplicated) 22 23 6.250000 $303.1300 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.272223 $6361.5000 $5000.3000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 201 201 351.529367 $17576.4800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 49 93.000003 $4650.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 93 93 142.955555 $7147.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 175 296.430170 $14821.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 29 29 70.119047 $3505.9600 $50.0000
INTR -INTR INTERPRETER 16 16 213.246033 $10662.3100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 42.285714 $2870.3600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 14 14 88.266666 $5991.5500 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.966667 $483.3500 $500.0200
SENS -V5264 EARMOLD 4 4 3.066667 $55.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 63.571427 $4315.2400 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 308 598 178182.333336 $89091.1700 $0.5000
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Subtotal (Total Children Is Unduplicated) 312 1194 179549.042875 $167532.4600 $0.9300
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Total 1225 179573.026208 $167835.5800 $0.9300
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Number of Children (Unduplicated) With at Least One Authorization 320