Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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 12 15 8.599998 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 15 8.599998 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 1.700000 $106.4700 $62.6300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.511111 $23.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 5.077777 $583.9400 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.511111 $24.7900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 16 15.841269 $768.3000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 10 2.899999 $140.6500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 29 9.122222 $442.4300 $48.5000
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Subtotal (Total Children Is Unduplicated) 40 65 35.663489 $2089.5600 $58.5900
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 87 111.861110 $5593.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.877778 $21.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 72 65.656348 $3282.8100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 489 602 528.758723 $26437.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.922222 $48.0600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 39 48 367.142853 $18357.1800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 7 43.821429 $2974.6000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 9 10 58.928572 $4000.0700 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -V5264 EARMOLD 2 3 1.500000 $27.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 1.055555 $52.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 24 139.071429 $9440.1800 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 546 1248 5850.181689 $58501.8600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 149 190 10365.446817 $5182.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 618 2299 17536.735636 $134175.6600 $7.6500
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Total 2379 17580.999123 $136265.2200 $7.7500
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Number of Children (Unduplicated) With at Least One Authorization 637