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 2555 FSPSA's found of which 8 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 5 5 2.095555 $77.5300 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 2.095555 $77.5300 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.438889 $28.5900 $65.1400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 2.338889 $119.4000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 22 10.870633 $554.9400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 11 4.473362 $228.3600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 2.555554 $130.4500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 40 44 52.925451 $2701.8500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 22.203175 $1133.4700 $51.0500
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Subtotal (Total Children Is Unduplicated) 70 97 95.805953 $4897.0700 $51.1100
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 377 596 587.465054 $29373.1700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 22 217.504765 $10875.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 706 1713 8250.355416 $82503.6000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 14 131.464285 $9391.8100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.571429 $261.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 8 79.428571 $5674.3800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 60.142856 $3437.7700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 24 174.321429 $12453.5200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 28.128571 $390.4300 $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) 751 2453 10546.040311 $155042.7500 $14.7000
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Total 2555 10643.941819 $160017.3500 $15.0300
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Number of Children (Unduplicated) With at Least One Authorization 775