Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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 3936 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 13 13 5.119259 $189.4000 $37.0000
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Subtotal (Total Children Is Unduplicated) 13 13 5.119259 $189.4000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 0.705556 $45.9600 $65.1400
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.488889 $36.6700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 2.928571 $162.5400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 13 4.417459 $331.3300 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 17 20 7.128233 $363.8900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 77 84 49.117988 $2507.4500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 32 38 25.511130 $1302.3300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 50 51 38.267457 $1953.5400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 127 136 117.117596 $5978.8400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 22.642064 $1155.8800 $51.0500
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Subtotal (Total Children Is Unduplicated) 254 359 270.324943 $13988.4400 $51.7500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.322222 $77.0700 $239.1800
CONIF -CONIF CONSULT, FACE TO FACE 377 596 587.465054 $29373.1700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 53 469.428566 $11735.7300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 663 782 7167.439634 $358372.5000 $50.0000
INTR -T1013 INTERPRETER 1 1 1.285714 $64.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 716 1740 8425.132400 $84251.3700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 80 87 572.825718 $40922.6900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 23.571429 $1348.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 74 85 628.466669 $44897.6900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 15 16 147.857142 $8451.5200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 114 125 873.714288 $62418.2300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 10.000000 $572.0000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 49.419048 $685.9400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 22 28 656.823013 $328.4100 $0.5000
TRAV -TRAVS Travel by mile 24 37 352.406351 $156.8200 $0.4500
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Subtotal (Total Children Is Unduplicated) 861 3564 19966.157248 $643655.7100 $32.2400
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Total 3936 20241.601450 $657833.5500 $32.5000
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Number of Children (Unduplicated) With at Least One Authorization 887