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: 07-01-14 and 09-30-14 Date of Report: 11-19-14 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 3 3 2.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.088889 $4.3100 $48.5100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.022222 $117.5500 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.422222 $20.4800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.200000 $9.7000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 0.883334 $42.8400 $48.5000
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Subtotal (Total Children Is Unduplicated) 9 12 2.616667 $194.8900 $74.4800
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 19 9.438890 $471.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 22.886510 $1144.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 11.283334 $564.1700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 111 47.888097 $2394.4100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 11 36.863490 $1843.1700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 12.857143 $872.7400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 7 7 26.509524 $1799.4600 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.766667 $38.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 29.252381 $1985.6500 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 272 398 1158.366666 $11583.6700 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 24 51 2628.196032 $1314.1000 $0.5000
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Subtotal (Total Children Is Unduplicated) 311 674 3984.308734 $24011.9900 $6.0300
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Total 689 3989.436512 $24206.8800 $6.0700
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Number of Children (Unduplicated) With at Least One Authorization 315