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: 10-01-13 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 11 11 3.950001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 3.950001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.022222 $10.2400 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.022222 $8.6000 $8.4100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.022222 $21.4700 $21.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 8.511938 $383.0400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.722221 $658.0400 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 2.965079 $143.8100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 11 3.944443 $191.3000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 2.127777 $103.1900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 3.266666 $158.4300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 27 8.362708 $405.5800 $48.5000
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Subtotal (Total Children Is Unduplicated) 43 70 37.967498 $2083.7000 $54.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.022222 $5111.0000 $4999.8900
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 7.155556 $357.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 2.250229 $112.5200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 22 10.961871 $548.0900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 20 20 32.433337 $810.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 0.372603 $18.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.533333 $113.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 9.083332 $454.1600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 22.266670 $556.6800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 13 83.273810 $4163.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 10.066668 $251.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 35 194.571431 $9728.5800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 46.495238 $2324.7700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 57 402.153964 $27298.2400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 16.285715 $884.6400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 42 42 312.404762 $21206.0400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 10 10 69.642859 $3783.0000 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 1.115221 $72.4900 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 1.619331 $369.2000 $228.0000
SENS -V5264 EARMOLD 4 4 5.722221 $103.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 22.571428 $1128.5800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 129 978.621433 $66428.8300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.571429 $519.9200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 8 49.714286 $656.2300 $13.2000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 191 285 130724.936351 $65362.4700 $0.5000
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Subtotal (Total Children Is Unduplicated) 206 692 133018.845300 $212364.3600 $1.6000
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Total 773 133060.762799 $214448.0600 $1.6100
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Number of Children (Unduplicated) With at Least One Authorization 219