IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 38,500.00 0 59 0.00 1 065004500 MERCYONE SIOUXLAND MEDICAL CENTER 4,600.00 0 23 0.00 1 065036600 BROOKHAVEN HOSPITAL 11,439.15 0 15 0.00 1 065534000 CHEROKEE REGIONAL MEDICAL CENTER 0.00 0 3 0.00 1 065536500 HAMILTON COUNTY PUBLIC HOSPITAL 0.00 0 17 0.00 1 065538100 BURGESS MEMORIAL HOSPITAL 0.00 0 3 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 248,422.14 9 216 0.00 5 TOTAL: 302,961.29 9 336 0.00 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 5,091.36 0 6 0.00 1 080008000 CREST HAVEN CARE CENTER 36.85 0 16 0.00 1 080008900 BETTENDORF HEALTH CARE CENTER 0.00 0 10 0.00 1 080009500 ADEL ACRES 0.00 0 0 0.00 1 080010000 THE COTTAGES 300.93 0 45 0.00 1 080010800 PREMIER ESTATES OF MUSCATINE 0.00 0 30 0.00 1 080017500 DENISON CARE CENTER 0.00 0 6 1,373.82- 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,729.60 0 59 0.00 2 080017800 CEDAR FALLS HEALTH CARE CENTER 338.66 0 30 0.00 1 080018100 GRUNDY CARE CENTER 2,323.81 0 12 488.03 1 080021000 THE REHAB CENTER OF DES MOINES 1,565.28 0 59 0.00 1 080021800 IVY AT DAVENPORT 59.66 0 8 0.00 1 080021900 BETHANY HOME 0.00 0 1 0.00 1 080022700 BETHANY LUTHERAN HOME 20,364.39 0 92 8,894.37 1 080024000 WINDMILL MANOR 0.00 0 22 0.00 1 080025900 PILLAR OF CEDAR VALLEY 17,977.92 0 61 0.00 1 080028900 NORWALK NURSING AND REHABILITATION 0.00 0 4 0.00 1 080029100 GRANGER NURSING & REHAB CENTER 11,340.84 10 62 7,397.38 2 080034600 ARBOR COURT 5,554.05 0 31 1,678.25 1 080066500 AZRIA HEALTH LONGVIEW 7,133.03 0 32 2,007.01 1 080066900 EAGLE POINT HEALTH CARE CENTER 3,116.72 0 24 3,082.00 1 080067300 ASPIRE OF GOWRIE 8,869.72 0 31 0.00 1 080070800 ENNOBLE NURSING AND REHAB 0.00 0 19 0.00 1 080071600 HARMONY WEST DES MOINES 689.23 0 12 2,993.45 2 080071900 HARMONY CEDAR RAPIDS 0.00 0 26 0.00 1 080072000 HARMONY UTICA RIDGE 0.00 0 14 0.00 1 080107600 EASTERN STAR MASONIC HOME 14,836.20 0 61 3,144.00 1 080120900 EVANS MEMORIAL HOME 0.00 0 6 0.00 1 080121700 GRACEWELL AN EVENTIDE COMMUNITY 0.00 0 1 0.00 1 080130800 FRIENDSHIP HAVEN 0.00 0 1 0.00 1 080136500 GLEN HAVEN VILLAGE 30,833.82 0 114 4,432.62 2 080194400 HOLY SPIRIT RETIREMENT HOME 7,013.77 0 31 1,192.24 1 080322100 SAVANNAH HEIGHTS 10,318.35 0 31 0.00 1 080339500 RICEVILLE FAMILY CARE & THERAPY CNT 0.00 0 12 0.00 1 080355100 SALEM LUTHERAN HOMES 486.36 0 23 0.00 2 080374200 ST ANTHONY REGIONAL HOSPITAL 39,449.14 0 123 0.00 1 080398100 THORNTON MANOR NURSING&CARE CENTER 79.39 0 0 0.00 1 080477300 ABCM HEALTHY LIVING HOME CARE 450.74 0 0 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,655.76 0 31 0.00 1 080509300 TRADITIONS MEMORY CARE OF NEWTON 21,719.63 0 92 2,293.29 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 9,736.94 0 62 5,229.24 2 080548100 SUNNY HILL CARE CENTER 5,357.23 0 30 2,237.87 1 080604200 IOWA VETERANS HOME 2,369,161.09 35 5,726 473,515.05 172 080734700 CARLISLE CARE CENTER FOR WELLNESS & 7,897.09 0 53 892.00 1 080740400 MAPLE MANOR VILLAGE 107.06 0 10 0.00 1 080792500 ATLANTIC SPECIALTY CARE 451.81 0 49 0.00 1 080797400 CENTERVILLE SPECIALTY CARE 4,341.80 0 17 0.00 1 080799000 CHEROKEE SPECIALTY CARE 0.00 0 24 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080809700 PANORA SPECIALTY CARE 25,189.60 0 92 0.00 1 080810500 CRESTON SPECIALTY CARE 0.00 0 7 0.00 1 080814700 ELDORA SPECIALTY CARE 358.86 0 2 124.00 1 080815400 HERITAGE SPECIALTY CARE 0.00 0 15 0.00 1 080818800 LYON SPECIALTY CARE 6,179.29 0 31 712.01 1 080820400 SOUTHRIDGE SPECIALTY CARE 220.63 0 9 0.00 1 080932700 FONDA SPECIALTY CARE 5,386.70 0 30 1,109.80 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 69,293.20 15 119 426.50 2 TOTAL: 2,730,016.51 60 7,500 520,475.29 234 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 504.58 0 122 3,874.00 2 011170800 PARK PLACE 1,016.36 0 124 3,434.00 4 011515400 CEDAR VALLEY RANCH 468.27 0 60 1,685.13 2 030019700 HOPE HAVEN ADMIN 0.00 0 2 71.78 2 030025100 SCENIC ACRES 1,193.36 6 139 4,010.69 5 030030700 SUSAN HESPEN 613.36- 0 61 1,575.93- 1 030032800 RISE LTD 318.59 17 14 794.00 1 030053000 CEDAR VALLEY RANCH 4,320.08 12 360 9,031.00 12 030056100 PRIDE GROUP 2,671.25 6 363 10,499.00 10 030056600 PRAIRIE VIEW 629.88 0 109 3,282.13 2 030063200 CARE 125.29 0 61 2,064.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 2,662.91 17 102 1,608.00 3 030067300 PARK PLACE 298.59 0 31 814.00 1 030070700 AREA RESIDENTIAL CARE 2,813.87 0 183 3,754.00 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 1,221.42 3 205 6,243.70 7 030091900 PRIDE GROUP 1,423.95 10 145 4,139.00 6 030094000 LIBERTY SQUARE 298.59 0 31 814.00 1 030125900 NISHNA PRODUCTIONS RES COOR 740.95 29 33 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 61 2,178.54 1 030235000 PRIDE GROUP 617.18 13 49 1,608.00 3 030263200 HORIZONS UNLIMITED 617.18 2 60 1,608.00 2 030294900 DAVID GIOVANNONI 68.59 0 31 1,044.00 1 030302100 KEVIN BANWART 256.27 3 28 856.32 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 115.70 0 30 961.00 1 030382600 HANDICAPPED DEV CENTER 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 030448100 MELISSA GLADFELTER 430.68 0 12 0.00 1 030459500 PRIDE GROUP 637.18 0 62 1,588.00 2 030464300 ABBE HEALTH 6,328.48 7 455 10,252.70 14 030475000 THE PRIDE GROUP 1,442.34 21 285 9,540.00 1 030475400 PRAIRIE VIEW MGMT 601.29 0 61 1,588.00 1 030476500 HILLCREST 1,655.19 0 301 9,147.70 9 030481800 HILLCREST 1,166.69 0 121 3,176.00 3 030493500 PRIDE GROUP 1,923.61 0 185 4,716.04 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 3 28 994.00 1 030550500 JULIA LINNANE 298.59 0 31 814.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030552100 VF SHERIDAN SPRINGS 1,174.36 0 124 3,276.00 4 030552700 SHERIDAN SPRINGS 1,642.10 3 183 5,033.44 6 030557100 VERA FRENCH SHERIDAN SPRING 154.59 0 31 958.00 1 030558200 SHELLEY FIEDLER 561.29 2 59 1,628.00 1 030571300 BRENDA HENRY SCHREIBER 463.29 0 61 1,726.00 1 030571800 EDWARD PARROTT 298.59 0 31 814.00 1 030578800 COUNTRY CARE 753.75 0 93 2,584.02 3 030587200 CEDAR VALLEY RANCH INC 450.18 0 62 1,775.00 2 030587400 ARCBEACON HILL RCF 337.29 0 61 1,852.00 1 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030606900 ABBE CENTER BUS OFFICE 1,008.80 4 116 3,298.00 4 030612900 HORIZONS UNLIMITED OF PAC INC 955.77 12 81 2,382.00 3 030613600 ADELINE COMM. LIVING HOME 714.29 16 45 1,475.00 1 030614900 VERA FRENCH COMM MENTAL 2,072.47 2 246 6,828.25 8 030615300 BUNKER HILL COMMUNITY LIVING HOME 341.29 7 54 1,848.00 1 030623200 OPTIMAE LIFE SERVICES 1,763.87 0 183 4,804.00 3 030625400 JUSTIN HAY 295.59 0 31 817.00 1 030645300 OPTIMAE CALHOUN 525.40 0 60 1,628.00 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 030679300 HANDICAPPED DEV GRP HM #8 298.59 7 24 814.00 1 030679400 THE PRIDE GROUP 250.70 3 27 826.00 1 030680600 ABBE CENTER FOR CMH 282.70 0 30 794.00 1 030680700 THE PRIDE GROUP 0.00 0 10 358.90 1 030685300 COUNTRY CARE CENTER CORP 318.59 0 31 794.00 1 030745400 NISHNA PRODUCTIONS 722.08 11 82 2,615.69 3 032437600 SIRF 601.29 0 61 1,588.00 1 033540600 MOUNTAIN, ELLEN 726.85 0 61 1,462.44 1 035497700 NORTH IOWA TRANS CENTER 318.59 0 31 794.00 1 036348100 PARK PLACE FOR 542.18 0 62 1,683.00 2 036376200 HILLCREST 767.99 1 90 2,498.00 3 036377000 COUNTRY CARE CENTER 1,078.29 0 93 2,259.48 3 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 318.59 0 31 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 855.46 0 214 6,825.00 1 038225900 EPIC HOUSE 298.59 0 31 814.00 1 038614400 RISE GROUP HOME 2,843.90 12 298 8,282.00 10 039090600 JENNIFER NEUZIL % HILLCRES RCF 0.00 0 30 1,076.70 1 039096300 EXCEPTIONAL PERSONS INC 298.59 0 31 814.00 1 039162300 DOUGLAS BAKER 823.29 0 61 1,366.00 1 039409800 PRIDE GROUP 282.70- 0 30 794.00- 1 039460100 PRIDE GROUP 601.29 0 61 1,588.00 1 039702600 KEVIN C RINGER 397.29 0 61 1,792.00 1 040526600 ROBERT HEFFLEFINGER % ARC 137.29 14 47 2,052.00 1 040847600 PRIDE I 398.45 4 27 714.14 1 040965600 JOAN ROUTH 206.59 0 31 906.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 041207200 EXCEPTIONAL PERSONS INC 298.59 0 31 814.00 1 089006400 PRIDE III 898.88 0 92 2,403.00 2 089360200 HORIZONS UNLIMITED OF PAC INC 924.57 0 92 2,377.31 1 089663900 PRIDE GROUP @ PRIMGHAR 120.59 0 31 992.00 1 TOTAL: 73,704.13 250 8,167 228,308.84 235 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 41,838.35 0 31 277.01 1 TOTAL: 41,838.35 0 31 277.01 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 8 AS OF 01/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/27/24 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 14,423.37 0 31 0.00 1 088025200 COURAGE HOMES 12,215.12 10 21 0.00 1 088026000 HILLS AND DALES 14,349.88 4 27 0.00 1 088036900 PARK VIEW HOMES 11,056.77 0 31 0.00 1 088063300 BLUFF VIEW HOMES 12,503.91 3 28 0.00 1 088068200 PROGRESS INDUSTRIES WEST 13,453.99 4 27 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 29,139.14 10 62 1,220.96 3 088107800 WOODRIDGE HOUSE 13,594.55 2 29 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,968.33 0 31 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 14,294.86 6 25 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,423.68 0 31 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,377.08 0 31 1,046.60 1 088211800 CHILDSERVE HOMES KEYSTONE 14,359.27 3 28 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,402.21 1 30 0.00 1 088213400 CHILDSERVE HOMES JOHNSTON STONECRES 12,498.04 2 26 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,423.68 0 31 0.00 1 TOTAL: 243,483.88 45 489 2,267.56 18 ** END OF REPORT **