IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 03/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/23/24 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 15,600.00 0 26 0.00 1 065163800 ON WITH LIFE 9,728.13 0 0 0.00 1 065501300 MAHASKA HEALTH PARTNERSHIP 0.00 0 78 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 407,608.73 0 327 4,159.48 6 TOTAL: 432,936.86 0 431 4,159.48 9 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 03/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/23/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080006200 WEST BEND HEALTH AND REHABILITATION 0.00 0 29 0.00 1 080006300 CAREAGE HILLS REHAB & HEALTHCARE 14,300.45 0 61 773.26 1 080006900 GENESIS SENIOR LIVING CENTER 186.96 0 44 0.00 2 080017600 CASA DE PAZ HEALTH CARE CENTER 8,166.40 0 29 0.00 1 080017800 CEDAR FALLS HEALTH CARE CENTER 92.83 0 15 0.00 1 080021800 IVY AT DAVENPORT 76.12 0 2 0.00 1 080022800 ACCURA HEALTHCARE OF MILFORD 0.00 0 13 0.00 1 080029000 REGENCY PARK NURSING AND REHABILITA 5,891.12 0 31 1,720.00 1 080029300 ALTOONA NURSING & REHABILITATION 0.00 0 46 0.00 2 080029900 ACCURA HEALTHCARE OF SHENANDOAH 0.00 0 8 0.00 1 080066500 AZRIA HEALTH LONGVIEW 11,372.03 0 22 2,079.01 1 080066800 SILVER OAK NURSING & REHABILITATION 278.73 0 1 0.00 1 080067300 ASPIRE OF GOWRIE 8,297.48 0 29 0.00 1 080068200 WINDSOR PLACE SENIOR LIVING CAMPUS 21,535.09 0 109 8,191.39 2 080069600 MOUNT CARMEL BLUFFS 8,599.74 0 36 0.00 1 080070800 ENNOBLE NURSING AND REHAB 0.00 0 3 0.00 1 080071700 HARMONY DUBUQUE 14,890.60 0 60 3,524.00 1 080071800 HARMONY DAVENPORT 0.00 0 5 1,481.90 1 080071900 HARMONY CEDAR RAPIDS 7,155.45 0 30 1,660.05 1 080145600 GOOD SAMARITAN SOCIETY-FOREST CITY 447.33- 0 0 0.00 1 080147200 GOOD SAMARITAN SOCIETY-HOLSTEIN 61.50 0 0 0.00 2 080194400 HOLY SPIRIT RETIREMENT HOME 6,506.08 0 29 1,170.51 1 080203300 IOWA MASONIC HEALTH FACILITIES 8,067.99 0 30 1,535.61 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 8,644.01 0 35 1,784.74 2 080322100 SAVANNAH HEIGHTS 9,652.65 0 29 0.00 1 080355100 SALEM LUTHERAN HOMES 0.00 0 9 0.00 1 080377500 ST LUKE LUTHERAN HOME INC 22,009.26 0 78 0.00 1 080418700 WESLEY ON GRAND 2,373.17 0 13 1,999.90 1 080466600 NEW LONDON SPECIALTY CARE 8,626.99 0 31 0.00 1 080485600 PARK VIEW REHABILITATION CENTER 170.04 0 21 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 8,189.02 0 29 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 12,039.24 0 54 2,562.90 2 080532500 MONTEZUMA SPECIALTY CARE 12,521.50 0 50 1,604.00 1 080604200 IOWA VETERANS HOME 2,124,950.92 44 5,249 484,410.84 170 080705700 RUTHVEN COMMUNITY CARE CTR 10,501.78 0 46 880.00 1 080734700 CARLISLE CARE CENTER FOR WELLNESS & 7,236.61 0 32 892.00 1 080736200 OELWEIN HEALTHCARE CENTER 13,269.98 5 49 794.40 1 080795800 BELLE PLAINE SPECIALTY CARE 15,321.60 0 64 0.00 1 080812100 DUBUQUE SPECIALTY CARE 266.72 0 37 0.00 2 080815400 HERITAGE SPECIALTY CARE 8,819.41 0 92 5,739.00 1 080818800 LYON SPECIALTY CARE 5,705.69 0 29 741.01 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 20,421.48 0 92 7,813.32 2 080832900 WESTWOOD SPECIALTY CARE 0.00 0 28 0.00 1 080868300 BLACK HAWK LIFE CARE CENTER 0.00 0 31 0.00 1 TOTAL: 2,405,751.31 49 6,730 531,357.84 221 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 03/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/23/24 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 475.56 0 58 1,660.00 2 011170800 PARK PLACE 751.12 0 116 3,520.00 4 011515400 CEDAR VALLEY RANCH 227.78 0 29 840.00 1 030019700 HOPE HAVEN ADMIN 0.00 0 18 646.02- 1 030025100 SCENIC ACRES 703.34 0 87 2,500.00 3 030030700 SUSAN HESPEN 258.05 0 29 809.73 1 030032800 RISE LTD 247.78 7 22 820.00 1 030039200 COMPREHENSIVE SYSTEMS 1,306.10 0 155 4,401.00 5 030053000 CEDAR VALLEY RANCH 3,273.20 5 320 8,693.30 12 030056100 PRIDE GROUP 3,058.39 8 313 8,732.00 10 030056600 PRAIRIE VIEW 369.24 0 82 2,650.00 2 030061600 MEDIAPOLIS CARE FACILITY 3,431.47 0 363 9,764.00 3 030061800 PENN CENTER INC 2,422.22 0 178 4,022.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 227.78 0 29 840.00 1 030067300 PARK PLACE 227.78 0 29 840.00 1 030084800 COUNTRY CARE CENTER CORP 330.12 0 58 1,805.44 2 030085500 CEDAR VALLEY RANCH 796.90 0 149 4,689.28 6 030086900 HILLCREST FAMILY SERVICES 4,803.76 3 695 20,653.87 13 030091900 PRIDE GROUP 1,316.68 4 199 6,157.78 7 030123700 MICHAEL GIVANS 1,090.49 0 121 3,308.00 1 030125900 NISHNA PRODUCTIONS RES COOR 631.77 4 54 1,503.79 2 030136600 RINGGOLD CO GROUP HOME 532.34 0 87 2,671.00 3 030147700 HORIZONS UNLIMITED 0.00 0 15 552.30 1 030190300 PENN CENTER INC 463.25 0 137 4,509.48 1 030235000 PRIDE GROUP 43.78 0 29 1,024.00 1 030260700 LISA LEWIS 948.71 0 92 2,382.00 1 030263200 HORIZONS UNLIMITED 475.56 0 58 1,660.00 2 030294900 DAVID GIOVANNONI 62.42 0 60 2,146.78 1 030302100 KEVIN BANWART 262.89 4 25 804.89 1 030304200 DONNA HENDERSON 270.78 0 29 797.00 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 107.78 1 28 960.00 1 030339500 HILLCREST FAMILY SERVICES 74.78 0 29 993.00 1 030382600 HANDICAPPED DEV CENTER 227.78 0 29 840.00 1 030401800 ASHLIE RAGON 321.42 0 31 820.00 1 030411500 TRACY OLLINGER 232.37 4 56 1,948.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 263.78 0 29 804.00 1 030425100 THOMAS FAULKNER 0.00 0 29 1,067.78 1 030459500 PRIDE GROUP 495.56 0 58 1,640.00 2 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 218.65 0 31 922.77 1 030464300 ABBE HEALTH 298.59 0 31 814.00 1 030475000 THE PRIDE GROUP 81.78 0 29 986.00 1 030475400 PRAIRIE VIEW MGMT 247.78 2 27 820.00 1 030476500 HILLCREST 1,991.59 0 471 15,293.90 13 030481800 HILLCREST 495.56 4 72 2,302.76 3 030488400 HILLCREST 247.78 0 29 820.00 1 030493500 PRIDE GROUP 1,154.36 0 145 4,184.54 5 030497500 JAY BAKER 0.00 0 29 1,067.78 1 030524800 HDC 875.12 0 116 3,396.00 4 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 03/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/23/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030550500 JULIA LINNANE 227.78 0 29 840.00 1 030552100 VF SHERIDAN SPRINGS 853.93 0 116 3,417.19 4 030552700 SHERIDAN SPRINGS 1,197.23 1 173 5,209.45 6 030557100 VERA FRENCH SHERIDAN SPRING 325.56 0 58 1,810.00 2 030568200 NANCY NAILL 424.42 0 31 717.00 1 030571800 EDWARD PARROTT 227.78 0 29 840.00 1 030578800 COUNTRY CARE 536.32 0 87 2,667.02 3 030587200 CEDAR VALLEY RANCH INC 301.56 0 58 1,834.00 2 030612900 HORIZONS UNLIMITED OF PAC INC 837.59 6 81 2,365.75 3 030614900 VERA FRENCH COMM MENTAL 1,274.43 3 171 5,132.25 6 030615200 HILLCREST FAMILY SERVICES 353.08 2 150 5,158.00 1 030623200 OPTIMAE LIFE SERVICES 1,650.42 0 180 4,977.18 3 030625400 JUSTIN HAY 223.78 0 29 844.00 1 030645300 OPTIMAE CALHOUN 529.20 0 60 1,680.00 1 030646400 HORIZONS UNLIMITED 1,470.59 0 116 2,800.53 4 030678600 NINTH STREET GROUP HOME 321.42 0 31 820.00 1 030679300 HANDICAPPED DEV GRP HM #8 227.78 0 29 840.00 1 030679600 NORTH IA TRANSITION CENTER 227.78 0 29 840.00 1 030680100 PRIDE IV 227.78 0 29 840.00 1 030680700 THE PRIDE GROUP 89.29 5 56 2,100.00 1 030685400 PRIDE GROUP @ PRIMGHAR 247.78 0 29 820.00 1 030745400 NISHNA PRODUCTIONS 272.76 1 57 1,862.80 2 035497700 NORTH IOWA TRANS CENTER 247.78 0 29 820.00 1 035515600 COMP SYSTEMS 2,386.66 0 278 7,849.30 9 035565100 NITC 0.00 0 8 294.56 1 035713700 RONALD BRUCE 474.49 0 121 3,924.00 1 036348100 PARK PLACE FOR 397.56 0 58 1,738.00 2 036376200 HILLCREST 632.85- 1 11 406.94 6 036377000 COUNTRY CARE CENTER 1,478.49 0 116 2,792.63 4 036800100 MAINSTREAM LIVING 1,099.83 0 58 1,035.73 2 037594900 MOSAIC 273.78 0 29 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 60.78 0 29 1,007.00 1 038614400 RISE GROUP HOME 2,178.30 12 278 8,499.50 10 038899100 COMP SYSTEMS MARY A 301.42 0 31 840.00 1 039409800 PRIDE GROUP 247.78 0 29 820.00 1 039460100 PRIDE GROUP 321.42 0 29 746.36 1 040965600 JOAN ROUTH 132.78 0 29 935.00 1 089360200 HORIZONS UNLIMITED OF PAC INC 53.90 0 0 53.90- 1 089501100 HILLCREST FAMILY SERVICES 2,238.81 2 213 5,506.37 1 089696900 HOPE HAVEN AREA DEV CTR CORP 0.00 0 18 646.02 1 TOTAL: 59,653.13 79 7,839 230,808.83 223 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 03/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/23/24 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 81,055.64 0 60 457.96 1 TOTAL: 81,055.64 0 60 457.96 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 03/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/23/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088025200 COURAGE HOMES 13,171.22 0 29 0.00 1 088036900 PARK VIEW HOMES 21,159.14 0 58 668.00 2 088063300 BLUFF VIEW HOMES 13,334.20 0 29 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 966.99 0 0 966.99- 2 088107800 WOODRIDGE HOUSE 17,360.59 0 29 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 21,718.39 0 29 0.00 1 088147400 CHILDSERVE HOMES URBANDALE HOUSE 13,510.81 0 29 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 13,510.81 0 29 0.00 1 088173000 HARMONY HOUSE HEALTH CARE CENTER 7,803.72- 0 0 7,803.72 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 12,490.43 0 29 1,020.38 1 088211800 CHILDSERVE HOMES KEYSTONE 13,510.81 0 29 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 13,510.81 0 29 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 13,510.81 0 29 0.00 1 TOTAL: 159,951.29 0 348 8,525.11 15 ** END OF REPORT **