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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5381 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 3 3.221429 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.022222 $37.8200 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 4.243651 $37.8200 $8.9100
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 15 4.744445 $309.0600 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 1.022222 $47.8400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 1.022222 $122.2600 $119.6000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.027778 $2.0900 $75.0600
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 8.000000 $444.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 6.027778 $452.0900 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 25 31 15.749999 $804.0300 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 120 136 69.337297 $3539.6500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 34 43 27.320632 $1394.7100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 84 92 41.172219 $2101.8300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 182 215 104.559521 $5337.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 333 548 280.984113 $14705.2900 $52.3300
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.333333 $318.9300 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 8 3.566667 $178.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 10 10 12.339682 $616.9900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 224 277 206.230139 $10311.4100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 70 46.299994 $2314.9700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 622 754 558.135673 $27906.5800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 97 111 1020.301585 $25507.5600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 784 968 8543.119837 $427156.3000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 831 2145 9882.397557 $98823.9800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 110 132 816.631753 $58340.1800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 57.142857 $3268.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 89 111 737.785720 $52707.4200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 13 17 134.214288 $7671.6900 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 2 4.000000 $948.4800 $237.1200
SENS -V5264 EARMOLD 1 2 1.022222 $18.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 108 134 733.878577 $52428.2700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.571429 $375.8800 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 50.000000 $694.0000 $13.8800
TRAV -TRAVS Travel by mile 50 68 65664.630952 $29220.7600 $0.4500
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Subtotal (Total Children Is Unduplicated) 953 4829 88479.602265 $798808.6900 $9.0300
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Total 5381 88764.830029 $813551.8000 $9.1700
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Number of Children (Unduplicated) With at Least One Authorization 963