Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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 16 16 20.072223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 20.072223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 32 11.929830 $578.5900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.253968 $56.7800 $45.2800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 3.333333 $200.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 8 2.700000 $121.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 5 3.055555 $351.3800 $115.0000
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 1 1 3.066667 $92.0000 $30.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 255 327 110.559513 $5362.0900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 190 248 103.990473 $5043.5300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 92 107 44.375397 $2152.2100 $48.5000
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Subtotal (Total Children Is Unduplicated) 499 737 284.398070 $13964.5500 $49.1000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 11 46.411906 $2320.6000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 2 0.177778 $8.8900 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 34 22.388887 $1119.4400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 61 37.144440 $1857.2000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 12 14.049999 $702.5000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 104 140 1113.428561 $27835.7800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1061 1456 11618.297510 $580915.9300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 0.511111 $25.5600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 316 423 3227.736482 $219099.0800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 7 76.857143 $4174.8800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 235 334 2323.715870 $157734.0600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 9 104.000000 $5649.2900 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 4 2.038889 $132.5300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 5 1.527778 $348.3400 $228.0000
SENS -V5264 EARMOLD 8 10 12.485713 $224.7400 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 33 89.871430 $4493.5700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 207 1404.078572 $95308.9200 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1028 1506 16375.272106 $163752.8600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 8 8 81.142856 $40.5700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 10 58.185713 $2909.3000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1317 4274 36609.322744 $1268654.0200 $34.6500
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Total 5027 36913.793037 $1282618.5700 $34.7500
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Number of Children (Unduplicated) With at Least One Authorization 1326