Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 1168 FSPSA's found of which 9 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 2 2 368.000000 $13616.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 368.000000 $13616.0000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.555556 $26.1600 $47.0900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.128767 $1.1300 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.128767 $2.8100 $21.8500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.128767 $2.9500 $22.9100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.136986 $6.4100 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.136986 $16.3900 $119.6100
EXIT -EXIT EXIT ASSESSMENT 34 38 2.232497 $111.6200 $50.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 0.221917 $33.2900 $149.9900
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 12.415080 $633.8000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 0.098782 $5.0400 $51.0600
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Subtotal (Total Children Is Unduplicated) 42 52 16.184105 $839.5900 $51.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071233 $356.0000 $4997.6800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 3.160883 $158.0500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 62 78 80.875615 $4043.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 115 220 721.147623 $36057.4300 $50.0000
CONIP -CONIP CONSULT, PHONE 3 5 14.295237 $357.3800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 71 76 720.865621 $36043.3600 $50.0000
INTR -T1013 INTERPRETER 6 6 63.434051 $3171.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 52 56 473.929288 $4739.3000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 13.142857 $938.9300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 4.790481 $342.2300 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.136986 $32.4900 $237.1400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 13 116.428570 $8317.6700 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 511 623 5391.694916 $2695.8400 $0.5000
TRAV -TRAVS Travel by mile 22 25 158.862622 $70.6900 $0.4400
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Subtotal (Total Children Is Unduplicated) 640 1114 7762.841539 $97324.9900 $12.5400
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Total 1168 8147.025644 $111780.5800 $13.7200
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Number of Children (Unduplicated) With at Least One Authorization 651