Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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: 07-01-17 and 09-30-17 Date of Report: 11-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3080 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 5 16.238095 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 5 16.238095 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 5 2.427777 $117.7400 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.511111 $10.9100 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 78 80 59.716666 $1286.8900 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.983333 $44.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.455555 $167.3800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 4.594444 $229.7200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 1.533333 $115.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 24 42 48.136506 $3610.2200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 44 81 51.149998 $3836.2400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 4 2.983333 $223.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 24 40 25.088886 $1881.6500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 53 99 65.316662 $3625.0500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 31 242.500000 $13458.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 19 35.533333 $2665.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 170 425 565.930937 $33072.5400 $58.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 2.444444 $12222.0000 $4999.9100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.144444 $57.2200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 31 32 11.283333 $2595.1600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 49 111.243649 $5562.1800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 231 348 438.345476 $21917.2700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 12 13 16.976985 $424.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 6.377778 $318.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 6.127778 $306.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 2 3.066667 $76.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 8.133334 $406.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 18 63.114286 $4627.5300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 110.555553 $2763.8900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 652 861 5250.369008 $262518.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 671 1251 5925.342260 $59253.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 14 65.914286 $4708.9300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 22.904762 $1310.1500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 11.714286 $836.8700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.933333 $224.8300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.511111 $33.2200 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.944444 $215.3200 $227.9900
SENS -V5264 EARMOLD 2 2 3.344444 $60.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 34.442856 $2460.5900 $71.4400
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Subtotal (Total Children Is Unduplicated) 675 2650 12101.234517 $382975.2300 $31.6500
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Total 3080 12683.403549 $416047.7700 $32.8000
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Number of Children (Unduplicated) With at Least One Authorization 675