Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 60 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
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 3.855556 $176.1200 $45.6800
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Subtotal (Total Children Is Unduplicated) 3 4 3.855556 $176.1200 $45.6800
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
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Subtotal (Total Children Is Unduplicated) 5 5 5.000000 $290.5500 $58.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 3.033333 $75.8300 $25.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.900000 $72.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.283333 $14.1700 $49.9900
CONOP -CONOP CONSULT, OT, PHONE 4 4 9.000000 $225.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 4.142857 $207.1500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 3 2.500000 $125.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 80.571429 $4350.8700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 135.499999 $11018.8600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 10 10 119.309523 $9702.2600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 12 148.638094 $12087.2700 $81.3200
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Subtotal (Total Children Is Unduplicated) 34 51 506.878568 $42878.8900 $84.5900
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Total 60 515.734124 $43345.5700 $84.0500
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Number of Children (Unduplicated) With at Least One Authorization 39