Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1394 FSPSA's found
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.219052 $8.1100 $37.0100
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Subtotal (Total Children Is Unduplicated) 1 1 0.219052 $8.1100 $37.0100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 1.632725 $79.1900 $48.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.583333 $29.7800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 7 6.966667 $355.6500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.161111 $8.2200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 6.172222 $315.0900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.511111 $26.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 4.681746 $239.0100 $51.0500
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Subtotal (Total Children Is Unduplicated) 19 24 20.708915 $1053.0300 $50.8500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 31 26.579363 $1328.9600 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 4 9 2.872221 $143.6100 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 9.571429 $239.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 49 55 454.811611 $22740.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 990 1250 10463.035461 $104630.5300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 60.571428 $4327.2300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 39.500000 $2821.8700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 6 38.785715 $2770.8400 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 1 8.285714 $4.1400 $0.5000
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Subtotal (Total Children Is Unduplicated) 1010 1369 11104.012942 $139007.0900 $12.5200
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Total 1394 11124.940909 $140068.2300 $12.5900
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Number of Children (Unduplicated) With at Least One Authorization 1017