Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1900 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 96 104 65.994436 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 96 104 65.994436 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 35 28.904958 $1401.9000 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.022222 $84.1100 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 0.810960 $93.2500 $114.9900
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.250000 $12.7600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 53 63 34.703413 $1771.6000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.077778 $3.9700 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 64 77 56.664165 $2892.7100 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.238889 $12.2000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.511111 $26.0900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.011111 $51.6200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 46 62 37.100686 $1894.0000 $51.0500
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Subtotal (Total Children Is Unduplicated) 165 251 164.295293 $8295.2500 $50.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 34 36.795054 $183975.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 35 38 63.700001 $3185.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 127 156 230.249209 $11512.4700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 1.255556 $62.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 84 101 152.877777 $7643.8900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.744444 $37.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 205 279 360.387307 $18019.3900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 7 8 7.477777 $373.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 459 661 3602.852350 $180142.7000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 8 42.085714 $2104.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 55.200000 $2760.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 78 496.942848 $35501.6700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $89.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 63 90 596.611104 $42621.9500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 6.142857 $438.8500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 0.810960 $184.8900 $227.9800
SENS -V5264 EARMOLD 4 4 0.975343 $17.5600 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 75 424.642855 $30336.5000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.166666 $127.2300 $13.8800
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Subtotal (Total Children Is Unduplicated) 632 1545 6091.489251 $519365.6500 $85.2600
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Total 1900 6321.778980 $527660.8900 $83.4700
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Number of Children (Unduplicated) With at Least One Authorization 713