Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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: 01-01-14 and 03-31-14 Date of Report: 06-03-14 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 76 79 61.955554 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 76 79 61.955554 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 27 8.445053 $409.5900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.500000 $22.6400 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 1.922223 $27.6000 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.922223 $35.4900 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.922223 $19.2600 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.922223 $16.1700 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 1.922223 $14.9000 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.922223 $40.3700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 2.805556 $175.7100 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 1.922223 $42.3300 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 15 15 22.511112 $1350.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.233334 $10.5000 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.000000 $230.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 0.651826 $32.5900 $50.0000
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 1 1 1.900000 $57.0000 $30.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.338889 $16.4400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 25 7.383334 $358.1000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 14 3.638889 $176.4900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 26 7.500000 $363.7500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.000000 $1100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.138889 $6.9500 $50.0000
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Subtotal (Total Children Is Unduplicated) 96 150 82.502443 $4506.5300 $54.6200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 27.930953 $1396.5500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 0.349505 $17.4800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 311 327 655.636512 $32781.8500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 0.500000 $12.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 288 320 602.538884 $30126.9100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 336 362 642.690472 $32134.5000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.433333 $10.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 778 894 1141.455547 $57072.7500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.066667 $51.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 12.000000 $300.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 127 143 1202.561118 $60127.9700 $50.0000
INTR -INTR INTERPRETER 5 5 31.044444 $1552.2200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 56 345.604763 $23459.6300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 67 73 401.488097 $27253.0100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.105556 $52.8000 $500.2100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 1.163394 $75.6200 $65.0000
SENS -V5264 EARMOLD 5 5 2.438890 $43.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 7 5.460317 $273.0100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 92 104 600.747621 $40778.7700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.400000 $5.2800 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 24.171429 $2417.1400 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 2052 3381 25833.619131 $258336.0400 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 316 677 170765.496819 $85382.7500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 5.100000 $255.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2468 6383 202305.003452 $653918.1700 $3.2300
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Total 6612 202449.461449 $658424.7100 $3.2500
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Number of Children (Unduplicated) With at Least One Authorization 2562