IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 02/29/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/24/24 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 18,600.00 0 31 0.00 1 065502700 PALO ALTO COUNTY HOSPITAL 0.00 0 3 0.00 1 065503500 MANNING REGIONAL HEALTHCARE CENTER 0.00 0 1 0.00 1 065534000 CHEROKEE REGIONAL MEDICAL CENTER 0.00 0 4 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 276,770.57 14 177 1,054.12 7 TOTAL: 295,370.57 14 216 1,054.12 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 02/29/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/24/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080006900 GENESIS SENIOR LIVING CENTER 79.64 0 1 0.00 1 080008900 BETTENDORF HEALTH CARE CENTER 0.00 0 31 0.00 1 080009500 ADEL ACRES 200.99 0 28 0.00 1 080010000 THE COTTAGES 120.81 0 9 0.00 1 080017300 LENOX CARE CENTER 31,788.12 0 150 4,709.45 1 080017400 GARDEN VIEW CARE CENTER 0.00 0 14 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 13,798.40 0 49 0.00 2 080021000 THE REHAB CENTER OF DES MOINES 538.48 0 60 1,734.70 2 080021800 IVY AT DAVENPORT 19.09 0 3 0.00 1 080024000 WINDMILL MANOR 5,889.89 0 43 2,998.41 2 080025300 RED OAK REHAB AND CARE CENTER 25,173.65 0 89 0.00 1 080025900 PILLAR OF CEDAR VALLEY 5,286.74 0 31 0.00 1 080066500 AZRIA HEALTH LONGVIEW 7,061.03 0 31 2,079.01 1 080067300 ASPIRE OF GOWRIE 8,869.72 0 31 0.00 1 080068200 WINDSOR PLACE SENIOR LIVING CAMPUS 8,247.38 0 31 206.94 1 080068400 NEWTON HEALTH CARE CENTER 4,241.82 0 31 3,557.78 1 080071600 HARMONY WEST DES MOINES 914.00 0 0 914.00- 1 080072000 HARMONY UTICA RIDGE 0.00 0 20 0.00 1 080120900 EVANS MEMORIAL HOME 12,445.36 0 61 2,087.28 1 080147200 GOOD SAMARITAN SOCIETY-HOLSTEIN 9,961.24 0 50 5,688.76 2 080184500 HERITAGE HOUSE 6,242.28 0 30 2,098.32 1 080194400 HOLY SPIRIT RETIREMENT HOME 5,231.96 0 31 1,312.39 1 080203300 IOWA MASONIC HEALTH FACILITIES 7,246.28 0 30 2,357.32 1 080322100 SAVANNAH HEIGHTS 10,318.35 0 31 0.00 1 080373400 ST. FRANCIS MANOR 17,424.89 0 61 2,565.42 1 080374200 ST ANTHONY REGIONAL HOSPITAL 9,618.43 0 29 0.00 1 080399900 TIMELY MISSION NURSING HM 0.00 0 0 0.00 1 080476500 CONCORD CARE CENTER 8,664.97 0 31 1,004.86 1 080485600 PARK VIEW REHABILITATION CENTER 114.29 0 6 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 15,993.46 0 67 2,926.00 2 080513500 ACCURA HEALTHCARE OF AMES 22,025.20 0 82 0.00 1 080514300 ACCURA HEALTHCARE OF CHEROKEE 5,690.17 0 29 1,295.93 2 080515000 ACCURA HEALTHCARE OF SIOUX CITY 13,614.88 0 62 3,150.54 2 080524200 PERRY LUTHERAN HOME 6,060.22 0 30 2,211.68 1 080547300 SUNNY VIEW CARE CENTER 12,332.06 0 62 3,531.26 1 080604200 IOWA VETERANS HOME 2,454,644.53 37 5,915 482,974.81 175 080734700 CARLISLE CARE CENTER FOR WELLNESS & 7,774.36 0 31 892.00 1 080805500 LAPORTE CITY SPECIALTY CARE 11,747.04 0 61 2,751.44 1 080815400 HERITAGE SPECIALTY CARE 295.54- 0 0 180.00- 1 080818800 LYON SPECIALTY CARE 6,150.29 0 31 741.01 1 080820400 SOUTHRIDGE SPECIALTY CARE 7,585.47 0 31 623.64 1 080821200 MECHANICSVILLE SPECIALTY CARE 1,345.25 0 14 2,191.57 1 080827900 RAVENWOOD SPECIALTY CARE 7,650.67 0 35 1,901.98 2 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 10,519.14 0 18 0.00 2 TOTAL: 2,782,335.01 37 7,480 536,498.50 227 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 02/29/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/24/24 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 622.84 0 62 1,660.00 2 011102100 CARE 52.42 0 31 1,089.00 1 011170800 PARK PLACE 1,045.68 0 124 3,520.00 4 011515400 CEDAR VALLEY RANCH 301.42 0 31 840.00 1 030025100 SCENIC ACRES 924.26 0 93 2,500.00 3 030030700 SUSAN HESPEN 0.00 0 0 0.00 1 030032800 RISE LTD 321.42 8 23 820.00 1 030053000 CEDAR VALLEY RANCH 5,724.06 4 428 10,126.38 12 030056100 PRIDE GROUP 3,476.20 6 336 9,116.24 12 030056600 PRAIRIE VIEW 171.42 0 31 970.00 1 030063200 CARE 75.42 0 31 1,066.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 622.84 9 53 1,660.00 2 030067300 PARK PLACE 301.42 0 31 840.00 1 030084800 COUNTRY CARE CENTER CORP 477.40 0 62 1,805.44 2 030085500 CEDAR VALLEY RANCH 1,486.52 0 186 5,362.00 6 030086900 HILLCREST FAMILY SERVICES 8,332.67 19 764 20,057.50 11 030091900 PRIDE GROUP 1,832.16 1 185 5,016.36 6 030125900 NISHNA PRODUCTIONS RES COOR 779.05 13 49 1,503.79 2 030136600 RINGGOLD CO GROUP HOME 1,314.55 0 154 4,299.00 3 030147700 HORIZONS UNLIMITED 38.42 0 31 1,103.00 1 030235000 PRIDE GROUP 438.84 0 62 1,844.00 2 030263200 HORIZONS UNLIMITED 622.84 1 61 1,660.00 2 030302100 KEVIN BANWART 281.66 0 31 859.76 1 030304200 DONNA HENDERSON 344.42 0 31 797.00 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 181.42 1 30 960.00 1 030339500 HILLCREST FAMILY SERVICES 300.01 4 58 1,954.00 1 030382600 HANDICAPPED DEV CENTER 301.42 0 31 840.00 1 030411500 TRACY OLLINGER 306.01 4 58 1,948.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 337.42 0 31 804.00 1 030425100 THOMAS FAULKNER 47.42 0 31 1,094.00 1 030448100 MELISSA GLADFELTER 321.42 1 30 820.00 1 030459500 PRIDE GROUP 642.84 0 62 1,640.00 2 030464300 ABBE HEALTH 911.30 0 70 1,601.00 2 030475000 THE PRIDE GROUP 229.06 0 31 912.36 1 030475400 PRAIRIE VIEW MGMT 321.42 0 31 820.00 1 030476500 HILLCREST 7,572.92 23 943 27,444.64 14 030481800 HILLCREST 1,601.44 9 146 4,048.00 3 030488400 HILLCREST 640.01 0 62 1,614.00 1 030492900 NORTH IA TRANSITION CENT 301.42 0 31 840.00 1 030493500 PRIDE GROUP 1,522.56 0 155 4,184.54 5 030497500 JAY BAKER 35.42 0 31 1,106.00 1 030524800 HDC 1,169.68 1 123 3,396.00 4 030537700 L ARCHE CLINTON 114.42 8 23 1,027.00 1 030550500 JULIA LINNANE 301.42 0 31 840.00 1 030552100 VF SHERIDAN SPRINGS 1,148.49 0 124 3,417.19 4 030552700 SHERIDAN SPRINGS 1,639.07 1 185 5,209.45 6 030557100 VERA FRENCH SHERIDAN SPRING 151.42 0 31 990.00 1 030571800 EDWARD PARROTT 301.42 0 31 840.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 02/29/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/24/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030578800 COUNTRY CARE 757.24 0 93 2,667.02 3 030587200 CEDAR VALLEY RANCH INC 448.84 0 62 1,834.00 2 030597500 SARAH KUNATH 137.42 0 31 1,004.00 1 030612900 HORIZONS UNLIMITED OF PAC INC 1,341.21 7 116 3,159.75 3 030614900 VERA FRENCH COMM MENTAL 2,067.29 0 247 7,027.25 8 030625400 JUSTIN HAY 297.42 0 31 844.00 1 030646400 HORIZONS UNLIMITED 1,333.68 0 124 3,232.00 4 030664500 L'ARCH CLINTON IV 228.42 0 31 913.00 1 030671800 L'ARCH CLINTON II 301.42 0 31 840.00 1 030679300 HANDICAPPED DEV GRP HM #8 301.42 0 31 840.00 1 030679400 THE PRIDE GROUP 286.59 0 31 826.00 1 030679600 NORTH IA TRANSITION CENTER 368.20 0 10 0.00 1 030745400 NISHNA PRODUCTIONS 434.65 0 62 1,848.19 2 032034100 HOPE HAVEN 816.71 0 92 2,514.00 1 032437600 SIRF 321.42 0 31 820.00 1 033540600 MOUNTAIN, ELLEN 388.20 0 31 753.22 1 034414300 REDWOOD COURT 3,149.73 0 276 6,842.40 3 035497700 NORTH IOWA TRANS CENTER 321.42 0 31 820.00 1 036348100 PARK PLACE FOR 544.84 0 62 1,738.00 2 036376200 HILLCREST 3,170.32 4 306 8,128.56 6 036377000 COUNTRY CARE CENTER 1,773.05 0 124 2,792.63 4 036800100 MAINSTREAM LIVING 1,247.11 0 62 1,035.73 2 037587300 ADM OF THE ARCH 301.42 0 31 840.00 1 037594900 MOSAIC 347.42 0 31 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 134.42 0 31 1,007.00 1 038614400 RISE GROUP HOME 2,876.70 4 306 8,537.50 10 039090600 JENNIFER NEUZIL % HILLCRES RCF 32.01 2 60 2,222.00 1 039139100 HOPE HAVEN 1,845.42 0 184 4,816.00 2 039162300 DOUGLAS BAKER 458.42 0 31 683.00 1 039409800 PRIDE GROUP 321.42 0 31 820.00 1 039460100 PRIDE GROUP 347.42 0 31 794.00 1 039702600 KEVIN C RINGER 167.09 0 31 974.33 1 040847600 PRIDE I 427.28 2 29 714.14 1 040965600 JOAN ROUTH 206.42 0 31 935.00 1 089360200 HORIZONS UNLIMITED OF PAC INC 521.42 0 31 620.00 1 TOTAL: 78,010.82 132 8,042 221,102.37 208 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 02/29/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/24/24 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 20.00- 0 0 20.00 1 TOTAL: 20.00- 0 0 20.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 02/29/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/24/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088003400 FAITH HOPE AND CHARITY 42,658.50 0 0 0.00 2 088003900 VILLAGE NORTHWEST UNLIMITED 14,423.37 0 31 0.00 1 088025200 COURAGE HOMES 3,125.90 0 0 0.00 1 088026000 HILLS AND DALES 14,702.68 0 31 0.00 1 088036900 PARK VIEW HOMES 14,028.21 0 31 646.00 2 088061700 CRESTVIEW GROUP HOME 114.88 0 0 114.88- 1 088063300 BLUFF VIEW HOMES 4,458.64 0 0 0.00 1 088068200 PROGRESS INDUSTRIES WEST 18,031.37 4 27 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 35,114.35 4 58 2,808.51 3 088107800 WOODRIDGE HOUSE 13,635.35 0 31 0.00 1 088127600 BALANCE AUTISM 42,946.34 0 92 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 12,816.53 0 31 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 14,530.12 0 31 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,535.92 0 31 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 54,009.03 23 100 0.00 2 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,474.32 0 31 1,061.60 1 088211800 CHILDSERVE HOMES KEYSTONE 14,504.59 1 30 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,534.18 0 31 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,535.92 0 31 0.00 1 TOTAL: 356,180.20 32 617 4,401.23 24 ** END OF REPORT **