IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 08/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/27/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 065036600 BROOKHAVEN HOSPITAL 23,640.91 0 31 0.00 1 065578700 RINGGOLD COUNTY HOSPITAL 0.00 0 7 0.00 1 065580300 JEFFERSON COUNTY HEALTH CENTER 18,160.56 0 11 0.00 1 065583700 CENTRAL COMMUNITY HOSPITAL 0.00 0 23 0.00 2 065993800 CHILDSERVE HABILITATION CENTER 112,059.42 0 93 0.00 4 TOTAL: 153,860.89 0 165 0.00 9 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 08/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/27/23 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 11.76 0 1 0.00 1 080009900 ACCURA HEALTHCARE OF KNOXVILLE 0.00 0 13 0.00 1 080010900 PREMIER ESTATES OF TOLEDO 19,503.72- 0 0 19,503.72 1 080017000 ROSE HAVEN NURSING HOME 0.00 0 29 0.00 1 080017400 GARDEN VIEW CARE CENTER 8,356.45 4 58 1,798.38 1 080017800 CEDAR FALLS HEALTH CARE CENTER 3,231.28 0 13 0.00 1 080018100 GRUNDY CARE CENTER 6,775.81 0 31 488.11 1 080020400 THE BRIDGES AT ANKENY 0.00 0 23 0.00 1 080021000 THE REHAB CENTER OF DES MOINES 141.87 0 4 0.00 2 080021800 IVY AT DAVENPORT 82.52 0 5 0.00 1 080021900 BETHANY HOME 3,923.11 0 19 1,467.00 1 080024000 WINDMILL MANOR 0.00 0 26 0.00 1 080028500 MONTROSE HEALTH CENTER 0.00 0 2 0.00 1 080029100 GRANGER NURSING & REHAB CENTER 0.00 0 6 0.00 1 080029800 CONTINENTAL SPRINGS LLC 180.36 0 13 0.00 1 080034600 ARBOR COURT 0.00 0 22 0.00 1 080066500 AZRIA HEALTH LONGVIEW 9,724.83 0 59 3,678.01 2 080067300 ASPIRE OF GOWRIE 6,790.55 0 31 0.00 1 080067900 KEOTA HEALTH CARE CENTER 0.00 0 14 0.00 1 080121700 GRACEWELL AN EVENTIDE COMMUNITY 1,373.19 0 31 6,427.03 1 080123300 FAITH LUTHERAN HOME 434.76 0 19 0.00 1 080142300 GOOD SAMARITAN SOCIETY-DAVENPORT 1,118.26 0 44 0.00 2 080232200 THE VINTON LUTHERAN HOME 3,314.78 0 23 1,475.20 1 080325400 PLEASANT VIEW INC 8,509.20 0 40 0.00 1 080357700 SCENIC MANOR 0.00 0 22 0.00 1 080400500 TITONKA CARE CENTER 390.31 0 14 0.00 1 080473200 OAKWOOD CARE CENTER 4,245.74 0 18 1,102.06 1 080476500 CONCORD CARE CENTER 2,926.36 0 16 797.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,655.76 0 31 0.00 1 080498900 LONGHOUSE-NORTHSHIRE LTD 0.00 0 31 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 12,675.14 0 62 2,291.04 2 080604200 IOWA VETERANS HOME 2,284,332.35 65 5,781 532,934.27 173 080734700 CARLISLE CARE CENTER FOR WELLNESS & 7,037.45 0 52 892.00 1 080811300 CRESTVIEW SPECIALTY CARE 9,333.17 0 53 3,925.47 2 080818800 LYON SPECIALTY CARE 6,221.14 0 31 712.01 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 0.00 0 18 0.00 1 080825300 PARKRIDGE SPECIALTY CARE 17,999.73 0 92 7,757.34 1 080826100 NORTHCREST SPECIALTY CARE 0.00 0 25 0.00 1 080827900 RAVENWOOD SPECIALTY CARE 0.00 0 8 0.00 1 080828700 RIDGEWOOD SPECIALTY CARE 9,037.24 0 47 1,988.96 1 080829500 STRATFORD SPECIALTY CARE 22,191.36 0 92 0.00 1 080879000 THE VILLAGE 0.00 0 31 0.00 1 080923600 HIAWATHA CARE CENTER 18,148.17 6 86 2,963.00 1 TOTAL: 2,436,658.93 75 7,036 590,200.60 220 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 08/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/27/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 011102100 CARE 288.18 0 62 1,937.00 2 011170800 PARK PLACE 996.36 0 124 3,454.00 4 011493400 COUNTRY CARE CENTER CORP 158.59 0 31 954.00 1 011515400 CEDAR VALLEY RANCH 540.05 0 62 1,685.13 2 011623600 ANDREW JACKSON CARE 1,599.54 0 186 5,076.00 6 030030700 SUSAN HESPEN 330.74 0 31 781.85 1 030039200 COMPREHENSIVE SYSTEMS 1,303.64 5 181 5,371.90 6 030053000 CEDAR VALLEY RANCH 4,838.26 7 427 10,738.00 14 030056100 PRIDE GROUP 3,368.34 9 393 10,696.00 10 030056600 PRAIRIE VIEW 456.29 12 59 2,091.90 2 030063200 CARE 795.27 0 93 2,542.50 3 030064600 NORTH IOWA TRANSITIONAL CENTER 318.59 0 31 794.00 1 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 1,113.95 0 155 4,449.00 5 030086900 HILLCREST FAMILY SERVICES 4,313.53 15 354 8,929.88 11 030091900 PRIDE GROUP 2,320.56 0 248 6,507.00 8 030093900 ANDREW JACKSON CARE 702.36 0 130 3,963.34 5 030125900 NISHNA PRODUCTIONS RES COOR 740.95 17 45 1,484.23 2 030136600 RINGGOLD CO GROUP HOME 451.18 0 62 1,774.00 2 030147700 HORIZONS UNLIMITED 44.59 0 31 1,068.00 1 030150900 CARE 10.75 0 31 1,101.84 1 030190300 PENN CENTER INC 3,088.38 0 397 11,159.95 13 030218500 MIKE HAMLETT % BRYCE HAMLETT 94.59 0 31 1,018.00 1 030235000 PRIDE GROUP 617.18 8 54 1,608.00 2 030263200 HORIZONS UNLIMITED 617.18 1 61 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 9 22 668.05 1 030304200 DONNA HENDERSON 315.59 0 31 797.00 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 183.59 1 30 929.00 1 030339500 HILLCREST FAMILY SERVICES 151.59 4 27 961.00 1 030361100 DAVID LANE % ANDREW JACKSON CARE 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 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 308.59 0 31 804.00 1 030425100 THOMAS FAULKNER 52.59 0 31 1,060.00 1 030459500 PRIDE GROUP 637.18 0 62 1,588.00 2 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 192.73 1 30 919.86 1 030464300 ABBE HEALTH 7,203.26 38 766 21,291.22 22 030475400 PRAIRIE VIEW MGMT 935.77 1 92 2,402.00 3 030476500 HILLCREST 3,901.06 10 544 15,982.00 16 030481800 HILLCREST 955.77 0 93 2,382.00 3 030488400 HILLCREST 318.59 0 31 794.00 1 030492000 COMP SYSTEMS 298.59 12 19 814.00 1 030493500 PRIDE GROUP 955.77 8 85 2,382.00 3 030497500 JAY BAKER 6.59 0 31 1,106.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 08/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/27/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030499600 EPIC GROUP HOME 227.59 0 31 885.00 1 030537700 L ARCHE CLINTON 118.59 8 23 994.00 1 030550500 JULIA LINNANE 298.59 0 31 814.00 1 030552100 VF SHERIDAN SPRINGS 798.27 5 88 2,539.50 3 030552700 SHERIDAN SPRINGS 1,695.10 9 177 4,980.44 6 030557100 VERA FRENCH SHERIDAN SPRING 154.59 0 31 958.00 1 030568200 NANCY NAILL 417.59 0 31 695.00 1 030573400 HILLCREST RCF 11.47 0 23 814.00 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 1,822.39 8 143 3,597.00 5 030612900 HORIZONS UNLIMITED OF PAC INC 637.18 8 54 1,588.00 2 030614900 VERA FRENCH COMM MENTAL 2,325.17 1 247 6,575.55 8 030615200 HILLCREST FAMILY SERVICES 298.59 0 31 814.00 1 030625400 JUSTIN HAY 295.59 0 31 817.00 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 1 30 794.00 1 030745400 NISHNA PRODUCTIONS 1,267.41 8 146 4,115.69 3 032437600 SIRF 318.59 0 31 794.00 1 033540600 MOUNTAIN, ELLEN 381.37 0 31 731.22 1 035515600 COMP SYSTEMS 2,376.68 5 274 7,636.63 9 036348100 PARK PLACE FOR 425.54 0 62 1,799.64 2 036376200 HILLCREST 2,286.83 28 219 6,578.00 8 036377000 COUNTRY CARE CENTER 1,078.29 0 93 2,259.48 3 036670800 BETH WYATT 362.59 2 29 750.00 1 036800100 MAINSTREAM LIVING 637.18 0 62 1,588.00 2 037587300 ADM OF THE ARCH 298.59 3 28 814.00 1 037594900 MOSAIC 318.59 0 31 794.00 1 038225900 EPIC HOUSE 298.59 0 31 814.00 1 038258000 BREESE REST HOME 537.29 0 61 1,652.00 1 038899100 COMP SYSTEMS MARY A 298.59 1 30 814.00 1 039090600 JENNIFER NEUZIL % HILLCRES RCF 19.59 0 31 1,093.00 1 039096300 EXCEPTIONAL PERSONS INC 298.59 0 31 814.00 1 039162300 DOUGLAS BAKER 429.59 0 31 683.00 1 039409800 PRIDE GROUP 382.18 0 62 1,843.00 2 039702600 KEVIN C RINGER 216.59 0 31 896.00 1 040062200 BREES REST HOME 183.59 0 31 929.00 1 040965600 JOAN ROUTH 206.59 0 31 906.00 1 041207200 EXCEPTIONAL PERSONS INC 298.59 3 28 814.00 1 089501100 HILLCREST FAMILY SERVICES 825.47 0 31 287.12 1 TOTAL: 74,628.80 248 8,261 229,817.57 263 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 08/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/27/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088008800 WOODWARD RESOURCE CENTER 44,689.91 0 31 0.00 1 TOTAL: 44,689.91 0 31 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 08/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/27/23 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 34,588.96 10 83 1,907.18 3 088003900 VILLAGE NORTHWEST UNLIMITED 14,217.53 0 31 0.00 1 088025200 COURAGE HOMES 12,995.82 0 31 0.00 1 088026000 HILLS AND DALES 14,647.19 0 31 0.00 1 088036900 PARK VIEW HOMES 21,467.54 0 62 646.00 2 088063300 BLUFF VIEW HOMES 12,580.15 2 29 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 38,876.93 6 87 474.25 3 088107800 WOODRIDGE HOUSE 13,635.35 0 31 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,968.33 0 31 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 14,337.80 4 27 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 116,081.09 0 258 0.00 1 088173000 HARMONY HOUSE HEALTH CARE CENTER 9,199.38 0 31 1,353.02 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 36,454.86 0 85 2,151.64 1 088211800 CHILDSERVE HOMES KEYSTONE 14,380.74 2 29 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,423.68 0 31 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,423.68 0 31 0.00 1 TOTAL: 407,279.03 24 908 6,532.09 21 ** END OF REPORT **