Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1906 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 25 28 2396.322223 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 44.000000 $1628.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 26 29 2440.322223 $1628.0000 $0.6700
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 29 31 39.664002 $1983.2000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 54 54 100.000000 $5000.0000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.655555 $33.4600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.511111 $26.0900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.511111 $26.0900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.511111 $26.0900 $51.0500
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Subtotal (Total Children Is Unduplicated) 90 96 152.025112 $7664.7200 $50.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.450000 $2250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.333333 $116.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 2.244444 $112.2200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.511111 $347.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 8 4.633335 $115.8400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 214 282 226.656348 $11332.8100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 201 258 336.872225 $8421.8100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 148 329 208.399993 $10419.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 99 209 232.416666 $5810.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 99 61.422218 $3071.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 37 87 99.888888 $2497.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 185 231 186.266666 $9313.3300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 190 241 289.927783 $7248.2100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.678571 $216.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 3 15.714286 $785.7200 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 38.571428 $2755.5600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $187.9400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.000000 $71.4400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 13.142857 $751.2500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.044444 $1388.2500 $455.9900
SENS -V5264 EARMOLD 2 2 1.511111 $27.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 8 59.285714 $4235.3800 $71.4400
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Subtotal (Total Children Is Unduplicated) 408 1781 1801.646024 $71696.2500 $39.7900
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Total 1906 4393.993359 $80988.9800 $18.4300
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Number of Children (Unduplicated) With at Least One Authorization 469