Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3216 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 66 71 118.689684 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 66 71 118.689684 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.252055 $11.3400 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.397260 $160.6900 $115.0000
EXIT -EXIT EXIT ASSESSMENT 15 15 30.000000 $1500.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
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Subtotal (Total Children Is Unduplicated) 21 22 34.649315 $1789.1300 $51.6400
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 5 4.633334 $231.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 22 28 28.866669 $1443.3500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 4 1.504109 $345.9700 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 129 137 11.945732 $597.4900 $50.0200
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 10 10 1.448612 $36.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 40 47 65.944445 $3297.2300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 12 13 10.200000 $255.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 17 24.505556 $1225.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 9 10 8.216666 $205.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 18 29.224999 $1461.2500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 5.483333 $137.0800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 32 46.359920 $2317.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 12 12.449998 $311.2500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 2 52.571428 $1314.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 73 86 2664.142859 $66603.5600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 703 898 6844.161894 $342208.4500 $50.0000
INTR -T1013 INTERPRETER 16 19 107.611393 $5380.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 858 1293 9752.161106 $97521.7200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 114 517.109531 $36942.3000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 12 67.240475 $3846.1600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 105 138 644.061913 $46011.7200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 6 35.014286 $2001.4200 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 0.838356 $54.5000 $65.0100
SENS -V5060 BEHIND EAR HEARING AID
2 2 0.397260 $90.5800 $228.0200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
4 5 2.504109 $1141.9200 $456.0200
SENS -V5264 EARMOLD 20 27 23.700001 $426.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 126 168 825.954769 $59006.1500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 9 10 161.357144 $2239.6400 $13.8800
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Subtotal (Total Children Is Unduplicated) 934 3123 21949.609897 $676654.7300 $30.8300
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Total 3216 22102.948896 $678443.8700 $30.6900
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Number of Children (Unduplicated) With at Least One Authorization 983