IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 12/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 065004500 MERCYONE SIOUXLAND MEDICAL CENTER 0.00 0 6 0.00 1 065163800 ON WITH LIFE 123,516.89 0 97 0.00 1 065504300 VAN BUREN CO MEMORIAL HOSP 0.00 0 5 0.00 1 065560500 DECATUR COUNTY HOSP SNF 0.00 0 10 0.00 1 065582900 REGIONAL HLTH SERVICES OF HOWARD CO 0.00 0 3 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 196,650.85 0 167 0.00 6 TOTAL: 320,167.74 0 288 0.00 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 12/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080006300 CAREAGE HILLS REHAB & HEALTHCARE 25,456.80 0 30 0.00 1 080006500 CLARION WELLNESS & REHAB CENTER 5,856.53 0 30 1,796.47 1 080008100 LAURENS CARE CENTER 1,836.87 0 22 2,641.01 1 080010900 PREMIER ESTATES OF TOLEDO 0.00 0 9 0.00 1 080011800 WESTVIEW ACRES CARE CENTER 0.00 0 30 332.57 1 080017300 LENOX CARE CENTER 587.17 0 29 0.00 1 080017500 DENISON CARE CENTER 4,338.91 0 31 2,759.16 1 080017600 CASA DE PAZ HEALTH CARE CENTER 0.00 0 25 0.00 1 080017800 CEDAR FALLS HEALTH CARE CENTER 234.88 0 29 0.00 1 080018100 GRUNDY CARE CENTER 6,541.57 0 30 488.03 1 080020400 THE BRIDGES AT ANKENY 15,552.90 0 62 5,974.12 2 080021000 THE REHAB CENTER OF DES MOINES 165.59 0 71 2,555.40 3 080021500 ACCURA HEALTHCARE OF STANTON 6,424.39 0 31 983.99 1 080021900 BETHANY HOME 0.00 0 1 0.00 1 080029300 ALTOONA NURSING & REHABILITATION 7,802.20 1 30 445.70 1 080034600 ARBOR COURT 191.49 0 29 0.00 1 080066500 AZRIA HEALTH LONGVIEW 5,472.59 0 30 2,007.01 1 080067300 ASPIRE OF GOWRIE 8,583.60 0 30 0.00 1 080068400 NEWTON HEALTH CARE CENTER 5,994.80 0 31 151.88 1 080071700 HARMONY DUBUQUE 16,359.67 0 66 4,593.24 1 080096100 DAVENPORT LUTHERAN HOME 23,403.15 0 94 2,053.93 2 080120900 EVANS MEMORIAL HOME 0.00 0 16 0.00 1 080194400 HOLY SPIRIT RETIREMENT HOME 22,668.25 0 91 3,082.02 1 080210800 KAHL HOME FOR THE AGED 18,990.73 0 61 1,107.34 1 080232200 THE VINTON LUTHERAN HOME 4,911.10 0 30 3,419.90 1 080248800 MAPLE HEIGHTS 5,051.00 0 30 2,610.10 1 080268600 METHODIST MANOR RETIREMENT COMM 8,672.56 0 31 0.00 1 080322100 SAVANNAH HEIGHTS 9,992.58 0 31 0.00 2 080377500 ST LUKE LUTHERAN HOME INC 4,134.40 0 16 0.00 1 080398100 THORNTON MANOR NURSING&CARE CENTER 185.47 0 0 0.00 1 080408800 VALLEY VIEW VILLAGE 7,031.74 0 31 287.36 1 080476500 CONCORD CARE CENTER 169.57 0 0 0.00 1 080477300 ABCM HEALTHY LIVING HOME CARE 17,902.89 0 61 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,408.80 0 30 0.00 1 080512700 ACCURA HEALTHCARE OF NEWTON EAST 4,714.60 0 21 884.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 11,709.58 0 58 2,291.04 2 080604200 IOWA VETERANS HOME 2,274,498.63 55 5,548 483,516.57 174 080732100 FLEUR HEIGHTS CENTER FOR WELLNESS & 15,650.45 0 61 3,139.66 1 080734700 CARLISLE CARE CENTER FOR WELLNESS & 7,494.80 0 30 892.00 1 080736200 OELWEIN HEALTHCARE CENTER 9,060.99 0 31 0.00 1 080811300 CRESTVIEW SPECIALTY CARE 1,687.68- 0 6 0.00 1 080812100 DUBUQUE SPECIALTY CARE 1,764.06- 0 6 0.00 1 080818800 LYON SPECIALTY CARE 5,956.99 0 30 712.01 1 080825300 PARKRIDGE SPECIALTY CARE 13,528.67 0 40 753.33 2 080827900 RAVENWOOD SPECIALTY CARE 2,385.13 0 14 1,482.51 1 080965700 HAPPY SIESTA NURSING HOME 0.00 0 0 0.00 1 TOTAL: 2,583,470.30 56 6,989 530,960.35 226 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 12/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 010506400 SCENIC ACRES 545.40 0 60 1,608.00 2 011170800 PARK PLACE 872.80 0 120 3,434.00 4 011515400 CEDAR VALLEY RANCH 262.70 0 30 814.00 1 030019700 HOPE HAVEN ADMIN 0.00 1 35 1,292.04 2 030025100 SCENIC ACRES 1,070.80 8 112 3,236.00 4 030030700 SUSAN HESPEN 289.90 0 30 786.80 1 030032800 RISE LTD 282.70 13 17 794.00 1 030053000 CEDAR VALLEY RANCH 3,889.40 9 351 9,031.00 12 030056100 PRIDE GROUP 3,470.53 4 502 14,621.37 11 030056600 PRAIRIE VIEW 1,522.71 0 139 3,466.00 2 030064600 NORTH IOWA TRANSITIONAL CENTER 282.70 0 30 794.00 1 030067300 PARK PLACE 262.70 0 30 814.00 1 030070700 AREA RESIDENTIAL CARE 1,460.77 0 93 1,877.00 3 030071800 MARGARET MILLER 262.70 0 30 814.00 1 030084800 COUNTRY CARE CENTER CORP 404.96 0 60 1,748.44 2 030085500 CEDAR VALLEY RANCH 1,217.20 0 180 5,243.00 6 030086900 HILLCREST FAMILY SERVICES 1,070.80 1 119 3,236.00 4 030091900 PRIDE GROUP 1,577.98 3 177 4,882.22 6 030094000 LIBERTY SQUARE 262.70 0 30 814.00 1 030125900 NISHNA PRODUCTIONS RES COOR 669.17 6 54 1,484.23 2 030136600 RINGGOLD CO GROUP HOME 379.40 0 60 1,774.00 2 030147700 HORIZONS UNLIMITED 8.70 0 30 1,068.00 1 030190300 PENN CENTER INC 2,271.75 0 330 9,571.95 11 030235000 PRIDE GROUP 545.40 0 60 1,608.00 2 030263200 HORIZONS UNLIMITED 843.99 1 90 2,422.00 2 030284600 STEVEN CAREY 260.95 0 30 815.75 1 030294900 DAVID GIOVANNONI 32.70 0 30 1,044.00 1 030302100 KEVIN BANWART 256.64 3 27 820.06 1 030304200 DONNA HENDERSON 279.70 0 30 797.00 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 147.70 1 29 929.00 1 030382600 HANDICAPPED DEV CENTER 262.70 13 17 814.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 272.70 0 30 804.00 1 030425100 THOMAS FAULKNER 16.70 0 30 1,060.00 1 030459500 PRIDE GROUP 565.40 0 60 1,588.00 2 030464300 ABBE HEALTH 2,051.04 0 296 8,572.40 10 030475400 PRAIRIE VIEW MGMT 883.99 4 88 2,417.89 2 030476500 HILLCREST 706.69 23 98 3,636.00 4 030488400 HILLCREST 282.70 0 30 794.00 1 030493500 PRIDE GROUP 1,178.76 0 120 3,128.04 4 030499600 EPIC GROUP HOME 191.70 0 30 885.00 1 030524800 HDC 1,016.80 2 118 3,290.00 4 030537700 L ARCHE CLINTON 82.70 4 26 994.00 1 030550500 JULIA LINNANE 262.70 0 30 814.00 1 030552100 VF SHERIDAN SPRINGS 1,030.80 0 120 3,276.00 4 030552700 SHERIDAN SPRINGS 1,426.76 2 178 5,033.44 6 030557100 VERA FRENCH SHERIDAN SPRING 118.70 0 30 958.00 1 030558200 SHELLEY FIEDLER 298.59 0 31 814.00 1 030562500 PRAIRIE VIEW RCF 1,040.81 0 29 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 12/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/23/23 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030571300 BRENDA HENRY SCHREIBER 249.59 0 31 863.00 1 030571800 EDWARD PARROTT 262.70 0 30 814.00 1 030578800 COUNTRY CARE 646.08 0 90 2,584.02 3 030587200 CEDAR VALLEY RANCH INC 378.40 1 59 1,775.00 2 030587400 ARCBEACON HILL RCF 186.59 0 31 926.00 1 030597500 SARAH KUNATH 104.70 0 30 972.00 1 030606900 ABBE CENTER BUS OFFICE 262.70 0 60 1,890.70 2 030612900 HORIZONS UNLIMITED OF PAC INC 565.40 7 53 1,588.00 2 030613600 ADELINE COMM. LIVING HOME 375.09 5 26 737.50 1 030614900 VERA FRENCH COMM MENTAL 1,749.65 2 208 5,787.25 7 030615300 BUNKER HILL COMMUNITY LIVING HOME 188.59 0 31 924.00 1 030625400 JUSTIN HAY 259.70 0 30 817.00 1 030646400 HORIZONS UNLIMITED 1,139.80 0 120 3,167.00 4 030664500 L'ARCH CLINTON IV 192.70 0 30 884.00 1 030671800 L'ARCH CLINTON II 262.70 0 30 814.00 1 030679300 HANDICAPPED DEV GRP HM #8 262.70 0 30 814.00 1 030680600 ABBE CENTER FOR CMH 317.08 0 30 759.62 1 030745400 NISHNA PRODUCTIONS 614.41 11 79 2,615.69 3 035497700 NORTH IOWA TRANS CENTER 1,004.92 0 28 0.00 1 036348100 PARK PLACE FOR 292.84 0 60 1,860.56 2 036376200 HILLCREST 1,090.80 1 119 3,216.00 4 036377000 COUNTRY CARE CENTER 970.62 0 90 2,259.48 3 036800100 MAINSTREAM LIVING 565.40 0 60 1,588.00 2 037587300 ADM OF THE ARCH 262.70 0 30 814.00 1 037594900 MOSAIC 282.70 0 30 794.00 1 038225900 EPIC HOUSE 262.70 0 30 814.00 1 038258000 BREESE REST HOME 286.59 0 31 826.00 1 038614400 RISE GROUP HOME 2,485.00 4 296 8,282.00 10 039096300 EXCEPTIONAL PERSONS INC 262.70 0 30 814.00 1 039409800 PRIDE GROUP 282.70 0 30 794.00 1 040062200 BREES REST HOME 183.59 0 31 929.00 1 040526600 ROBERT HEFFLEFINGER % ARC 86.59 4 27 1,026.00 1 040847600 PRIDE I 362.56 4 26 714.14 1 040965600 JOAN ROUTH 170.70 0 30 906.00 1 041207200 EXCEPTIONAL PERSONS INC 262.70 0 30 814.00 1 TOTAL: 53,530.18 137 6,252 175,702.59 203 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 12/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/23/23 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 35,999.30 0 30 83.07 1 TOTAL: 35,999.30 0 30 83.07 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 12/31/23 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/23/23 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 13,958.10 0 30 0.00 1 088025200 COURAGE HOMES 12,498.53 1 29 0.00 1 088026000 HILLS AND DALES 14,228.40 0 30 0.00 1 088036900 PARK VIEW HOMES 20,754.20 0 60 646.00 2 088063300 BLUFF VIEW HOMES 12,169.42 2 28 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 75,006.91 11 172 2,441.92 3 088107800 WOODRIDGE HOUSE 13,195.50 0 30 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,162.90 0 30 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 13,915.46 2 28 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 13,958.40 0 30 0.00 1 088173000 HARMONY HOUSE HEALTH CARE CENTER 0.61- 0 0 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 12,911.80 0 30 1,046.60 1 088211800 CHILDSERVE HOMES KEYSTONE 13,893.99 3 27 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 13,936.93 1 29 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 13,958.40 0 30 0.00 1 TOTAL: 268,548.33 20 583 4,134.52 18 ** END OF REPORT **