Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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 1416 FSPSA's found of which 5 had no frequency modifier field, FORCE FREQ MODIFIER to 0
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 41 42 73.918339 $2734.9900 $37.0000
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Subtotal (Total Children Is Unduplicated) 41 42 73.918339 $2734.9900 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 4 4 0.356165 $17.8100 $49.9900
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.288889 $193.3400 $150.0000
SCREEN-T1023 SCREENING 14 15 10.572222 $528.6100 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.213698 $10.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 21 23 12.430974 $750.6600 $60.3900
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 5.039682 $251.9900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 5.595238 $279.7700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.065753 $15.7400 $239.3700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 101 105 26.598072 $1329.9600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 0.705555 $17.6400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 53 122 188.647624 $9432.4200 $50.0000
CONIP -CONIP CONSULT, PHONE 11 29 40.633333 $1015.8300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 0.876208 $21.9100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 20 121.590480 $6079.5400 $50.0000
INTR -T1013 INTERPRETER 26 28 159.252574 $7962.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 629 968 6744.638292 $67446.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 12 44.952380 $3211.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 4 12.100000 $692.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 10 32.997620 $2357.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 16.928572 $967.6300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 4.146119 $269.5000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.131507 $31.1800 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.128767 $61.0800 $474.3600
SENS -V5264 EARMOLD 1 1 0.688889 $12.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 16 68.071430 $4863.0300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 53.214286 $738.6100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.133333 $0.0600 $0.4400
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Subtotal (Total Children Is Unduplicated) 650 1351 7575.135714 $107082.2500 $14.1400
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Total 1416 7661.485027 $110567.9000 $14.4300
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Number of Children (Unduplicated) With at Least One Authorization 698