IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT SNF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 18 SKILLED NURSING FACILITY VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 065000100 CENTER FOR COMPREHENSIVE SVCS D/B/A 21,700.00 0 31 0.00 1 065035800 AMBASSADOR OMAHA 37,151.84 0 38 0.00 2 065036600 BROOKHAVEN HOSPITAL 23,640.91 0 31 0.00 1 065502700 PALO ALTO COUNTY HOSPITAL 2,400.00 0 32 0.00 1 065539900 KOSSUTH REGIONAL HEALTH CENTER 0.00 0 10 0.00 1 065580300 JEFFERSON COUNTY HEALTH CENTER 46,226.88 0 28 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 112,059.42 0 93 0.00 3 TOTAL: 243,179.05 0 263 0.00 10 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT ICF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 20 INTERMEDIATE CARE FACILITY VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080000600 HARMONY DUBUQUE 0.00 0 16 0.00 1 080002700 NORTHCREST LIVING CENTER 0.00 0 7 0.00 1 080006900 GENESIS SENIOR LIVING CENTER 145.20 0 26 0.00 1 080009500 ADEL ACRES 1,182.01 0 15 3,060.74 1 080010900 PREMIER ESTATES OF TOLEDO 14,640.74 0 61 558.02 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,729.60 0 31 0.00 1 080017800 CEDAR FALLS HEALTH CARE CENTER 15,162.16 0 61 0.00 1 080018100 GRUNDY CARE CENTER 6,775.86 0 31 488.06 1 080023100 ACCURA HEALTHCARE OF SPIRIT LAKE 0.00 0 15 0.00 1 080025900 PILLAR OF CEDAR VALLEY 9,136.32 0 31 0.00 1 080066500 AZRIA HEALTH LONGVIEW 5,534.91 0 49 2,194.01 2 080067300 ASPIRE OF GOWRIE 6,790.55 0 31 0.00 1 080123300 FAITH LUTHERAN HOME 0.00 0 23 0.00 1 080142300 GOOD SAMARITAN SOCIETY-DAVENPORT 0.00 0 5 0.00 1 080160500 GOOD SHEPHERD HEALTH CENTER 9,814.30 0 31 3,534.63- 1 080181100 NEW HAMPTON NURSING & REHAB CENTER 2,513.40 0 15 421.35 1 080190200 HILLCREST HOME 175.03 0 8 0.00 1 080204100 IOOF HOME & COMMUNITY THERAPY CENTE 6,011.08 0 29 985.75 1 080225600 LONE TREE HEALTH CARE CENTER 105.56 0 0 0.00 1 080381700 STONEHILL CARE CENTER 88.54 0 0 0.00 2 080472400 WESTVIEW CARE CENTER 51.26 0 15 0.00 1 080481500 HERITAGE CARE & REHABILITATION CTR 0.00 0 7 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 12,433.75 0 61 2,291.04 2 080554900 LINN MANOR CARE CENTER 2,930.82 0 0 2,930.82- 1 080604200 IOWA VETERANS HOME 2,752,225.47 57 5,744 510,867.67 225 080734700 CARLISLE CARE CENTER FOR WELLNESS & 6,967.43 0 36 892.00 1 080799000 CHEROKEE SPECIALTY CARE 0.00 0 0 0.00 1 080802200 CORNING SPECIALTY CARE 0.00 0 3 0.00 1 080815400 HERITAGE SPECIALTY CARE 4,820.80 0 20 0.00 1 080818800 LYON SPECIALTY CARE 6,408.69 0 55 712.01 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 0.00 0 3 634.77 1 TOTAL: 2,872,643.48 57 6,429 516,639.97 258 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT RCF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 23 RESIDENTIAL CARE FACILITY VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 010506400 SCENIC ACRES 617.18 0 62 1,608.00 2 011102100 CARE 288.18 0 62 1,937.00 2 011170800 PARK PLACE 1,928.02 0 218 5,896.00 4 011493400 COUNTRY CARE CENTER CORP 158.59 0 31 954.00 1 011515400 CEDAR VALLEY RANCH 540.05 2 60 1,685.13 2 011623600 ANDREW JACKSON CARE 1,599.54 0 186 5,076.00 6 030014500 ABBE CENTER 684.85 4 61 1,648.00 1 030025100 SCENIC ACRES 617.18 0 62 1,608.00 2 030030700 SUSAN HESPEN 345.86 0 31 766.73 1 030032800 RISE LTD 318.59 7 24 794.00 1 030039200 COMPREHENSIVE SYSTEMS 1,303.64 5 181 5,371.90 6 030053000 CEDAR VALLEY RANCH 4,838.26 9 425 10,738.00 14 030056100 PRIDE GROUP 3,747.37 0 431 11,721.22 12 030056600 PRAIRIE VIEW 306.59 7 31 1,057.23 2 030061600 MEDIAPOLIS CARE FACILITY 1,254.36 0 124 3,196.00 4 030061800 PENN CENTER INC 1,112.59 0 31 0.00 1 030063200 CARE 795.27 0 93 2,542.50 3 030067300 PARK PLACE 298.59 0 31 814.00 1 030071800 MARGARET MILLER 298.59 0 31 814.00 1 030084800 COUNTRY CARE CENTER CORP 476.74 0 62 1,748.44 2 030085500 CEDAR VALLEY RANCH 1,389.54 6 180 5,286.00 6 030086900 HILLCREST FAMILY SERVICES 806.02 1 89 2,358.00 3 030091900 PRIDE GROUP 11,135.09 26 1,285 34,842.90 9 030093900 ANDREW JACKSON CARE 1,020.95 0 155 4,542.00 5 030123700 MICHAEL GIVANS 298.59 0 31 814.00 1 030125900 NISHNA PRODUCTIONS RES COOR 1,500.87 14 69 1,478.00 2 030136600 RINGGOLD CO GROUP HOME 538.16 5 79 2,476.60 3 030147700 HORIZONS UNLIMITED 44.59 0 31 1,068.00 1 030150900 CARE 10.75 0 31 1,101.84 1 030188400 ROBIN SCHARES 318.59 0 31 794.00 1 030190300 PENN CENTER INC 3,303.72 3 400 11,159.95 13 030218500 MIKE HAMLETT % BRYCE HAMLETT 94.59 0 31 1,018.00 1 030235000 PRIDE GROUP 617.18 0 62 1,608.00 2 030263200 HORIZONS UNLIMITED 617.18 0 62 1,608.00 2 030284600 STEVEN CAREY 296.84 0 31 815.75 1 030294900 DAVID GIOVANNONI 68.59 0 31 1,044.00 1 030302100 KEVIN BANWART 444.54 2 29 668.05 1 030304200 DONNA HENDERSON 315.59 0 31 797.00 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 183.59 1 30 929.00 1 030361100 DAVID LANE % ANDREW JACKSON CARE 298.59 0 31 814.00 1 030382600 HANDICAPPED DEV CENTER 298.59 0 31 814.00 1 030401800 ASHLIE RAGON 318.59 0 31 794.00 1 030409400 NEW HAMPTON GROUP HOME 298.59 0 31 814.00 1 030413500 ORION COLEMAN 298.59 0 31 814.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 308.59 0 31 804.00 1 030425100 THOMAS FAULKNER 52.59 0 31 1,060.00 1 030434800 NIKOLAUS BAEDER 318.59 0 31 794.00 1 030459500 PRIDE GROUP 637.18 0 62 1,588.00 2 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT RCF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 23 RESIDENTIAL CARE FACILITY VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 192.73 0 31 919.86 1 030464300 ABBE HEALTH 6,845.53 6 653 16,805.98 21 030475000 THE PRIDE GROUP 291.33 2 63 1,897.56 1 030475400 PRAIRIE VIEW MGMT 2,201.29 15 246 7,166.00 4 030476500 HILLCREST 946.61 0 93 2,318.00 3 030488400 HILLCREST 318.59 0 31 794.00 1 030492000 COMP SYSTEMS 298.59 4 27 814.00 1 030493500 PRIDE GROUP 2,135.57 15 191 5,064.25 5 030497500 JAY BAKER 6.59 0 31 1,106.00 1 030499600 EPIC GROUP HOME 227.59 0 31 885.00 1 030524800 HDC 1,160.36 1 123 3,290.00 4 030537700 L ARCHE CLINTON 118.59 1 30 994.00 1 030550500 JULIA LINNANE 298.59 0 31 814.00 1 030552100 VF SHERIDAN SPRINGS 798.27 2 91 2,539.50 3 030552700 SHERIDAN SPRINGS 1,924.80 0 216 5,827.44 6 030557100 VERA FRENCH SHERIDAN SPRING 154.59 0 31 958.00 1 030568200 NANCY NAILL 417.59 0 31 695.00 1 030578800 COUNTRY CARE 735.31 0 93 2,602.46 3 030587200 CEDAR VALLEY RANCH INC 450.18 0 62 1,775.00 2 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030606900 ABBE CENTER BUS OFFICE 853.36 1 123 3,597.00 4 030612900 HORIZONS UNLIMITED OF PAC INC 637.18 4 58 1,588.00 2 030614900 VERA FRENCH COMM MENTAL 2,017.58 3 214 5,770.55 7 030615200 HILLCREST FAMILY SERVICES 298.59 9 22 814.00 1 030615500 HANDICAPPED DEV GRP HM #7 298.59 0 31 814.00 1 030623700 COMMUNITY CARE OF KNOXVILLE 859.88 0 92 2,442.00 1 030625400 JUSTIN HAY 295.59 0 31 817.00 1 030645300 OPTIMAE CALHOUN 262.70 0 30 814.00 1 030646400 HORIZONS UNLIMITED 1,283.36 0 124 3,167.00 4 030664500 L'ARCH CLINTON IV 228.59 0 31 884.00 1 030671800 L'ARCH CLINTON II 298.59 0 31 814.00 1 030678600 NINTH STREET GROUP HOME 318.59 0 31 794.00 1 030678900 BRIDGET DRIVER 298.59 0 31 814.00 1 030679300 HANDICAPPED DEV GRP HM #8 298.59 0 31 814.00 1 030679400 THE PRIDE GROUP 573.18 16 46 1,652.00 1 030680100 PRIDE IV 178.92 0 43 1,364.35 1 030745400 NISHNA PRODUCTIONS 722.08 3 90 2,615.69 3 032034100 HOPE HAVEN 283.59 0 31 829.00 1 032437600 SIRF 318.59 0 31 794.00 1 033540600 MOUNTAIN, ELLEN 381.37 0 31 731.22 1 034261800 MASON CITY GROUP HOME 318.59 25 6 794.00 1 034414300 REDWOOD COURT 838.48 0 62 1,386.70 2 035515600 COMP SYSTEMS 2,376.68 5 274 7,636.63 9 035713700 RONALD BRUCE 147.59 0 31 965.00 1 036348100 PARK PLACE FOR 473.47 0 62 1,751.71 2 036376200 HILLCREST 3,045.97 0 273 6,752.00 5 036377000 COUNTRY CARE CENTER 1,078.29 0 93 2,259.48 3 036670800 BETH WYATT 362.59 3 28 750.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT RCF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 23 RESIDENTIAL CARE FACILITY VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 036800100 MAINSTREAM LIVING 637.18 0 62 1,588.00 2 037587300 ADM OF THE ARCH 298.59 0 31 814.00 1 037594900 MOSAIC 740.43 0 87 2,382.00 1 038258000 BREESE REST HOME 286.59 0 31 826.00 1 038614400 RISE GROUP HOME 3,142.49 7 334 9,096.00 11 038899100 COMP SYSTEMS MARY A 298.59 0 31 814.00 1 039096300 EXCEPTIONAL PERSONS INC 298.59 0 31 814.00 1 039139100 HOPE HAVEN 637.18 0 62 1,588.00 2 039162300 DOUGLAS BAKER 429.59 0 31 683.00 1 039409800 PRIDE GROUP 1,739.53 0 333 9,923.92 2 039702600 KEVIN C RINGER 216.59 0 31 896.00 1 040062200 BREES REST HOME 331.29 0 61 1,858.00 1 040965600 JOAN ROUTH 206.59 0 31 906.00 1 041207200 EXCEPTIONAL PERSONS INC 298.59 0 31 814.00 1 TOTAL: 95,939.19 214 10,539 288,147.54 281 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT ICF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 25 ICF ID STATE VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088002100 GLENWOOD RESOURCE CENTER 9,676.96 0 8 0.00 1 TOTAL: 9,676.96 0 8 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 06/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/24/23 BILLING DOCUMENTS REPORT ICF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 27 COMMUNITY BASED ICF/ID VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088003400 FAITH HOPE AND CHARITY 36,823.82 0 93 968.59 3 088003900 VILLAGE NORTHWEST UNLIMITED 13,746.02 0 31 0.00 1 088004600 ONE VISION - LIMESTONE 1,478.03- 0 0 0.00 1 088025200 COURAGE HOMES 25,327.24 0 62 776.00 2 088026000 HILLS AND DALES 13,746.33 0 31 0.00 1 088036900 PARK VIEW HOMES 21,566.74 0 62 646.00 2 088061700 CRESTVIEW GROUP HOME 2,029.87 0 7 1,075.82 1 088063300 BLUFF VIEW HOMES 12,766.95 0 31 50.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 39,062.94 4 89 502.95 3 088107800 WOODRIDGE HOUSE 13,656.74 0 31 0.00 1 088127600 BALANCE AUTISM 13,642.17 0 31 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,968.33 0 31 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 13,800.33 4 27 0.00 1 088173000 HARMONY HOUSE HEALTH CARE CENTER 9,269.75 0 31 1,353.02 1 088176300 BALANCE AUTISM YOUTH HOME 24,860.56 4 58 0.00 2 088211800 CHILDSERVE HOMES KEYSTONE 13,862.13 1 30 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 13,862.13 1 30 0.00 1 088213400 CHILDSERVE HOMES JOHNSTON STONECRES 13,820.93 3 28 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 13,882.73 0 31 0.00 1 TOTAL: 319,217.68 17 734 5,372.38 26 ** END OF REPORT **