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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.361111 $17.5100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 0.361111 $17.5100 $48.5000
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Subtotal (Total Children Is Unduplicated) 2 4 0.722222 $35.0300 $48.5000
EI Services, Class # 03
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
OCCT -97530 OT SESSION BY LICENSED OT 6 6 29.857143 $2026.7000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 2 15.785714 $1071.5300 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 1.115221 $72.4900 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 20 102.000003 $6923.7400 $67.8800
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) 193 418 131056.091841 $82844.3100 $0.6300
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Total 433 131060.764064 $82879.3400 $0.6300
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Number of Children (Unduplicated) With at Least One Authorization 204