IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 40,300.00 0 62 0.00 1 065004500 MERCYONE SIOUXLAND MEDICAL CENTER 5,342.26 0 21 0.00 3 065036600 BROOKHAVEN HOSPITAL 23,640.91 0 31 0.00 1 065502700 PALO ALTO COUNTY HOSPITAL 0.00 0 9 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 109,512.15 0 93 0.00 3 TOTAL: 178,795.32 0 216 0.00 9 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080002700 NORTHCREST LIVING CENTER 0.00 0 8 0.00 1 080006500 CLARION WELLNESS & REHAB CENTER 0.00 0 29 0.00 1 080006700 REGENCY CARE CENTER 21,180.95 0 92 3,855.00 1 080006900 GENESIS SENIOR LIVING CENTER 11,572.58 0 82 3,012.00 2 080009300 THE ALVERNO HEALTH CARE FACILITY 7,728.76 0 26 0.00 1 080017000 ROSE HAVEN NURSING HOME 0.00 0 26 173.00 1 080018100 GRUNDY CARE CENTER 6,775.81 0 31 488.11 1 080025900 PILLAR OF CEDAR VALLEY 27,114.24 0 92 0.00 1 080034600 ARBOR COURT 0.00 0 15 0.00 1 080048200 NEW ALDAYA LIFESCAPES 0.00 0 14 0.00 1 080066500 AZRIA HEALTH LONGVIEW 5,534.91 0 61 2,194.01 2 080067300 ASPIRE OF GOWRIE 6,790.55 0 31 0.00 1 080218100 LAKESIDE LUTHERAN HOME 770.70 0 3 0.00 1 080322100 SAVANNAH HEIGHTS 21,430.64 0 71 0.00 1 080357700 SCENIC MANOR 93.51 0 7 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,655.76 0 31 0.00 1 080514300 ACCURA HEALTHCARE OF CHEROKEE 4,773.06 0 18 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 12,675.14 0 62 2,291.04 2 080604200 IOWA VETERANS HOME 2,249,486.81 28 5,584 471,731.39 174 080727100 WAPELLO SPECIALTY CARE 11,863.35- 0 75 1,947.00- 1 080734700 CARLISLE CARE CENTER FOR WELLNESS & 6,967.43 0 31 892.00 1 080812100 DUBUQUE SPECIALTY CARE 16,119.68 0 68 3,873.00 1 080818800 LYON SPECIALTY CARE 6,221.14 0 31 712.01 1 080826100 NORTHCREST SPECIALTY CARE 19.31 0 1 0.00 1 080827900 RAVENWOOD SPECIALTY CARE 0.00 0 0 0.00 1 080932700 FONDA SPECIALTY CARE 2,866.56 0 12 0.00 1 080965700 HAPPY SIESTA NURSING HOME 0.00 0 1 0.00 1 TOTAL: 2,403,914.19 28 6,352 487,274.56 203 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 697.77 0 115 3,429.58 4 011493400 COUNTRY CARE CENTER CORP 0.00 0 25 897.25 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 030019700 HOPE HAVEN ADMIN 617.18 0 62 1,608.00 2 030030700 SUSAN HESPEN 325.43 0 31 787.16 1 030032800 RISE LTD 637.18 19 43 1,588.00 1 030039200 COMPREHENSIVE SYSTEMS 1,303.64 7 179 5,371.90 6 030053000 CEDAR VALLEY RANCH 4,838.26 9 425 10,738.00 14 030056100 PRIDE GROUP 2,620.56 12 420 12,596.00 10 030056600 PRAIRIE VIEW 173.59 0 31 939.00 1 030061800 PENN CENTER INC 318.59 0 31 794.00 1 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 030070700 AREA RESIDENTIAL CARE 1,604.33 0 97 1,877.00 4 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 3,718.80 0 320 7,766.00 6 030091900 PRIDE GROUP 1,788.90 6 204 5,748.00 7 030093900 ANDREW JACKSON CARE 480.77 0 103 3,215.90 4 030125900 NISHNA PRODUCTIONS RES COOR 740.95 12 50 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 2,666.54 0 341 9,571.95 11 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 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 0 31 668.05 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 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 0 31 919.86 1 030464300 ABBE HEALTH 5,154.32 22 576 16,307.90 20 030475400 PRAIRIE VIEW MGMT 617.18 1 61 1,608.00 2 030476500 HILLCREST 697.77 2 91 2,640.00 3 030492000 COMP SYSTEMS 298.59 3 28 814.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030493500 PRIDE GROUP 637.18 0 62 1,588.00 2 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 0 124 3,290.00 4 030550500 JULIA LINNANE 298.59 0 31 814.00 1 030552100 VF SHERIDAN SPRINGS 1,336.62 0 108 2,539.50 4 030552700 SHERIDAN SPRINGS 1,376.51 2 153 4,186.44 5 030557100 VERA FRENCH SHERIDAN SPRING 154.59 0 31 958.00 1 030568200 NANCY NAILL 417.59 0 31 695.00 1 030571300 BRENDA HENRY SCHREIBER 926.58 0 122 3,452.00 1 030571800 EDWARD PARROTT 298.59 0 31 814.00 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 030587400 ARCBEACON HILL RCF 186.59 0 31 926.00 1 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030606900 ABBE CENTER BUS OFFICE 1,171.95 7 148 4,391.00 5 030612900 HORIZONS UNLIMITED OF PAC INC 637.18 8 54 1,588.00 2 030613600 ADELINE COMM. LIVING HOME 375.09 9 22 737.50 1 030614900 VERA FRENCH COMM MENTAL 2,325.17 3 245 6,575.55 8 030615300 BUNKER HILL COMMUNITY LIVING HOME 188.59 0 31 924.00 1 030625400 JUSTIN HAY 295.59 0 31 817.00 1 030646400 HORIZONS UNLIMITED 1,283.36 0 124 3,167.00 4 030678600 NINTH STREET GROUP HOME 318.59 0 31 794.00 1 030679300 HANDICAPPED DEV GRP HM #8 298.59 0 31 814.00 1 030745400 NISHNA PRODUCTIONS 722.08 0 93 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 034414300 REDWOOD COURT 1,112.07 0 93 2,225.70 3 035515600 COMP SYSTEMS 2,376.68 10 269 7,636.63 9 036348100 PARK PLACE FOR 425.54 0 62 1,799.64 2 036376200 HILLCREST 597.18 0 62 1,628.00 2 036377000 COUNTRY CARE CENTER 1,078.29 0 93 2,259.48 3 036670800 BETH WYATT 362.59 0 31 750.00 1 036800100 MAINSTREAM LIVING 637.18 0 62 1,588.00 2 037594900 MOSAIC 318.59 0 31 794.00 1 038225900 EPIC HOUSE 298.59 0 31 814.00 1 038258000 BREESE REST HOME 250.70 1 29 826.00 1 038614400 RISE GROUP HOME 5,687.80 39 581 16,564.00 10 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 382.18 0 62 1,843.00 2 039702600 KEVIN C RINGER 216.59 0 31 896.00 1 040062200 BREES REST HOME 147.70 7 23 929.00 1 040526600 ROBERT HEFFLEFINGER % ARC 86.59 5 26 1,026.00 1 040847600 PRIDE I 763.18 3 59 1,462.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 040965600 JOAN ROUTH 206.59 0 31 906.00 1 041207200 EXCEPTIONAL PERSONS INC 298.59 1 30 814.00 1 TOTAL: 74,443.70 190 8,293 229,723.25 254 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 44,457.97 0 31 231.94 1 TOTAL: 44,457.97 0 31 231.94 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 09/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088003900 VILLAGE NORTHWEST UNLIMITED 14,217.53 0 31 0.00 1 088025200 COURAGE HOMES 12,917.75 1 30 0.00 1 088026000 HILLS AND DALES 14,470.79 2 29 0.00 1 088036900 PARK VIEW HOMES 21,467.54 0 62 646.00 2 088063300 BLUFF VIEW HOMES 12,732.63 0 31 0.00 1 088068200 PROGRESS INDUSTRIES WEST 70,835.47 14 148 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 114.61 0 0 114.61- 2 088107800 WOODRIDGE HOUSE 13,614.95 1 30 0.00 1 088127600 BALANCE AUTISM 27,104.54 0 62 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,968.33 0 31 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 14,380.74 2 29 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,423.68 0 31 0.00 1 088173000 HARMONY HOUSE HEALTH CARE CENTER 8,858.98 0 30 1,353.02 1 088176300 BALANCE AUTISM YOUTH HOME 49,283.82 14 110 0.00 2 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,347.86 0 31 1,075.82 1 088211800 CHILDSERVE HOMES KEYSTONE 23,963.46 15 38 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,402.21 1 30 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,423.68 0 31 0.00 1 TOTAL: 365,528.57 50 784 2,960.23 21 ** END OF REPORT **