IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 065509200 HANCOCK CO MEMORIAL HOSP 0.00 0 12 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 146,016.20 0 124 0.00 4 TOTAL: 169,657.11 0 167 0.00 6 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080006300 CAREAGE HILLS REHAB & HEALTHCARE 66,187.68 0 78 0.00 1 080006400 FORT DODGE HEALTH & REHABILITATION 0.00 0 16 0.00 1 080006900 GENESIS SENIOR LIVING CENTER 177.40 0 8 0.00 1 080008000 CREST HAVEN CARE CENTER 0.00 0 31 0.00 1 080009500 ADEL ACRES 19.31 0 1 0.00 1 080010000 THE COTTAGES 12,147.75 0 61 4,973.12 1 080010900 PREMIER ESTATES OF TOLEDO 0.00 0 3 0.00 1 080017300 LENOX CARE CENTER 782.91 0 30 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 527.40 0 30 0.00 1 080017800 CEDAR FALLS HEALTH CARE CENTER 28.73 0 1 0.00 1 080017900 IOWA CITY REHAB & HEALTH CARE CENTE 0.00 0 5 0.00 1 080018100 GRUNDY CARE CENTER 6,775.89 0 31 488.03 1 080021000 THE REHAB CENTER OF DES MOINES 0.00 0 53 0.00 2 080021800 IVY AT DAVENPORT 19.31 0 1 0.00 1 080024000 WINDMILL MANOR 0.00 0 18 0.00 2 080025900 PILLAR OF CEDAR VALLEY 9,136.32 0 31 0.00 1 080029100 GRANGER NURSING & REHAB CENTER 0.00 0 12 0.00 1 080029800 CONTINENTAL SPRINGS LLC 295.76 0 24 0.00 1 080030100 PERRY LUTHERAN HOMES EDEN ACRES CAM 7,384.75 0 31 1,538.60 1 080034600 ARBOR COURT 0.00 0 0 0.00 1 080066500 AZRIA HEALTH LONGVIEW 11,007.50 0 61 4,201.02 1 080067300 ASPIRE OF GOWRIE 8,869.72 0 31 0.00 1 080158900 GOOD SAMARITAN SOCIETY-WAUKON 0.00 0 4 0.00 1 080190200 HILLCREST HOME 13,947.16 0 62 4,920.06 1 080210800 KAHL HOME FOR THE AGED 16,558.26 0 62 3,248.26 1 080232200 THE VINTON LUTHERAN HOME 7,887.60 0 30 0.00 1 080237100 MADRID HOME FOR THE AGING 5.73 0 1 0.00 1 080322100 SAVANNAH HEIGHTS 10,545.24 0 56 0.00 2 080339500 RICEVILLE FAMILY CARE & THERAPY CNT 202.05 0 10 0.00 1 080355100 SALEM LUTHERAN HOMES 531.74 0 30 0.00 2 080377500 ST LUKE LUTHERAN HOME INC 2,116.40 0 10 0.00 1 080399900 TIMELY MISSION NURSING HM 0.00 0 57 0.00 1 080453400 SIBLEY SPECIALTY CARE 12,109.88 0 65 3,872.32 1 080476500 CONCORD CARE CENTER 17.43 0 0 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,655.76 0 31 0.00 1 080498900 LONGHOUSE-NORTHSHIRE LTD 0.00 0 6 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 12,433.75 0 61 2,291.04 2 080531700 STATE CENTER SPECIALTY CARE 8,518.90 0 61 3,765.24 1 080548100 SUNNY HILL CARE CENTER 0.00 0 20 0.00 1 080554900 LINN MANOR CARE CENTER 5,116.93 0 28 1,146.11 1 080604200 IOWA VETERANS HOME 2,379,213.55 35 5,661 478,146.36 180 080734700 CARLISLE CARE CENTER FOR WELLNESS & 7,774.36 0 31 892.00 1 080792500 ATLANTIC SPECIALTY CARE 9,430.92 0 52 678.27 2 080799000 CHEROKEE SPECIALTY CARE 3,413.86 0 43 7,604.03 1 080811300 CRESTVIEW SPECIALTY CARE 6,713.39 0 30 1,725.01 2 080818800 LYON SPECIALTY CARE 6,221.14 0 31 712.01 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 2,929.93 0 16 1,559.03 1 080825300 PARKRIDGE SPECIALTY CARE 7,361.91 0 31 2,052.79 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080832900 WESTWOOD SPECIALTY CARE 0.00 0 10 0.00 1 080879000 THE VILLAGE 182.13- 0 40 0.00 1 080910300 SHELL ROCK SENIOR LIVING 11,692.04 0 59 3,976.00 1 080923600 HIAWATHA CARE CENTER 24,575.53 0 89 0.00 1 080964000 THE AMBASSADOR SIDNEY INC 521.27 0 27 0.00 1 TOTAL: 2,680,673.03 35 7,191 527,789.30 239 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 1,898.90 0 210 5,638.00 3 011102100 CARE 288.18 0 62 1,937.00 2 011170800 PARK PLACE 1,016.36 0 124 3,434.00 4 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 030025100 SCENIC ACRES 3,499.52 14 354 9,708.00 4 030030700 SUSAN HESPEN 323.46 0 31 789.13 1 030032800 RISE LTD 601.29 19 42 1,588.00 1 030039200 COMPREHENSIVE SYSTEMS 1,300.95 2 153 4,262.00 5 030053000 CEDAR VALLEY RANCH 4,658.81 7 422 10,738.00 14 030056100 PRIDE GROUP 2,619.24 8 328 9,439.80 10 030061600 MEDIAPOLIS CARE FACILITY 4,766.21 0 489 12,784.00 4 030061800 PENN CENTER INC 6,496.09 0 181 0.00 1 030063200 CARE 379.18 0 81 2,527.91 3 030064600 NORTH IOWA TRANSITIONAL CENTER 2,507.88 0 92 794.00 2 030067300 PARK PLACE 298.59 0 31 814.00 1 030070700 AREA RESIDENTIAL CARE 1,353.10 0 90 1,877.00 3 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 1,432.54 1 185 5,243.00 6 030086900 HILLCREST FAMILY SERVICES 4,936.05 12 645 18,643.68 11 030091900 PRIDE GROUP 2,001.97 0 217 5,713.00 7 030093900 ANDREW JACKSON CARE 480.77 0 93 2,857.00 3 030123700 MICHAEL GIVANS 1,158.47 0 123 3,256.00 1 030125900 NISHNA PRODUCTIONS RES COOR 740.95 6 56 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 030260700 LISA LEWIS 1,521.17 0 153 3,970.00 1 030263200 HORIZONS UNLIMITED 318.59 0 31 794.00 1 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 030339500 HILLCREST FAMILY SERVICES 418.88 0 92 2,883.00 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 213.82 0 31 898.77 1 030464300 ABBE HEALTH 7,542.52 28 870 24,686.70 23 030476500 HILLCREST 5,290.40 3 887 26,651.70 13 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030481800 HILLCREST 2,759.64 3 273 7,146.00 3 030488400 HILLCREST 318.59 0 31 794.00 1 030492000 COMP SYSTEMS 433.72 3 28 678.87 1 030493500 PRIDE GROUP 1,322.32 0 124 3,128.04 4 030497500 JAY BAKER 6.59 0 31 1,106.00 1 030499600 EPIC GROUP HOME 227.59 0 31 885.00 1 030524800 HDC 915.77 0 93 2,422.00 3 030537700 L ARCHE CLINTON 201.29 2 59 1,988.00 1 030550500 JULIA LINNANE 298.59 0 31 814.00 1 030552100 VF SHERIDAN SPRINGS 1,174.36 0 124 3,276.00 4 030552700 SHERIDAN SPRINGS 1,642.10 0 186 5,033.44 6 030557100 VERA FRENCH SHERIDAN SPRING 154.59 0 31 958.00 1 030558200 SHELLEY FIEDLER 262.70 0 30 814.00 1 030568200 NANCY NAILL 417.59 0 31 695.00 1 030571300 BRENDA HENRY SCHREIBER 213.70 0 30 863.00 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 150.70 0 30 926.00 1 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030606900 ABBE CENTER BUS OFFICE 3,417.11 4 395 10,903.00 6 030612900 HORIZONS UNLIMITED OF PAC INC 637.18 1 61 1,588.00 2 030613600 ADELINE COMM. LIVING HOME 339.20 6 24 737.50 1 030614900 VERA FRENCH COMM MENTAL 2,040.20 1 216 5,747.93 7 030615300 BUNKER HILL COMMUNITY LIVING HOME 152.70 0 30 924.00 1 030623200 OPTIMAE LIFE SERVICES 935.77 0 93 2,402.00 3 030625400 JUSTIN HAY 295.59 0 31 817.00 1 030645300 OPTIMAE CALHOUN 298.59 0 31 814.00 1 030646400 HORIZONS UNLIMITED 1,283.36 0 124 3,167.00 4 030664500 L'ARCH CLINTON IV 421.29 5 56 1,768.00 1 030671800 L'ARCH CLINTON II 561.29 5 56 1,628.00 1 030678600 NINTH STREET GROUP HOME 318.59 1 30 794.00 1 030678900 BRIDGET DRIVER 597.18 0 62 1,628.00 1 030679300 HANDICAPPED DEV GRP HM #8 298.59 0 31 814.00 1 030680600 ABBE CENTER FOR CMH 352.97 0 31 759.62 1 030680700 THE PRIDE GROUP 62.59 2 29 1,050.00 1 030745400 NISHNA PRODUCTIONS 722.08 7 86 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 3 276 7,636.63 9 035713700 RONALD BRUCE 554.47 0 123 3,860.00 1 036348100 PARK PLACE FOR 221.86 0 62 2,003.32 2 036376200 HILLCREST 3,207.41 4 373 10,323.12 7 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 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 037587300 ADM OF THE ARCH 561.29 0 61 1,628.00 1 037594900 MOSAIC 318.59 0 31 794.00 1 038225900 EPIC HOUSE 298.59 0 31 814.00 1 038614400 RISE GROUP HOME 5,328.90 9 601 16,564.00 10 038736500 INDIANOLA RESIDENTIAL 196.59 0 31 916.00 1 038899100 COMP SYSTEMS MARY A 298.59 0 31 814.00 1 039090600 JENNIFER NEUZIL % HILLCRES RCF 39.18 0 92 3,262.70 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 318.59 0 31 794.00 1 039702600 KEVIN C RINGER 216.59 0 31 896.00 1 040526600 ROBERT HEFFLEFINGER % ARC 50.70 4 26 1,026.00 1 040847600 PRIDE I 398.45 0 31 714.14 1 040965600 JOAN ROUTH 206.59 0 31 906.00 1 041207200 EXCEPTIONAL PERSONS INC 298.59 0 31 814.00 1 TOTAL: 113,376.41 163 12,496 340,881.94 300 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 43,971.48 0 31 121.37 1 TOTAL: 43,971.48 0 31 121.37 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 8 AS OF 11/30/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/25/23 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 15,034.25 0 31 0.00 1 088025200 COURAGE HOMES 12,995.82 0 31 0.00 1 088026000 HILLS AND DALES 14,867.36 0 31 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 13,110.08 21 10 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 37,026.57 2 88 1,130.09 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 14,423.68 0 31 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,423.68 0 31 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 23,898.36 4 56 0.00 2 088189600 MOSAIC - MATTERN 11,601.64 0 31 736.05 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,347.86 0 31 1,075.82 1 088211800 CHILDSERVE HOMES KEYSTONE 14,359.27 3 28 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: 286,739.78 30 616 3,587.96 21 ** END OF REPORT **