IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 36,600.00 0 61 0.00 1 065004500 MERCYONE SIOUXLAND MEDICAL CENTER 0.00 0 0 0.00 1 065592800 SHELBY CO MYRTUE MEM HOSP 0.00 0 10 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 233,162.66 0 186 1,054.12 6 TOTAL: 269,762.66 0 257 1,054.12 9 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080000800 CRYSTAL HEIGHTS CARE CENTER 0.00 0 14 0.00 1 080006200 WEST BEND HEALTH AND REHABILITATION 0.00 0 31 0.00 1 080006700 REGENCY CARE CENTER 0.00 0 11 0.00 1 080007900 ELMWOOD CARE CENTER 18,618.72 0 91 1,818.00 3 080008100 LAURENS CARE CENTER 15,750.03 0 64 37.58 2 080009500 ADEL ACRES 12,810.37 0 61 2,547.60 1 080017300 LENOX CARE CENTER 2,357.61 0 0 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 11,305.32 0 31 0.00 2 080017800 CEDAR FALLS HEALTH CARE CENTER 16,573.68 0 61 3,092.12 2 080018100 GRUNDY CARE CENTER 11,246.40 0 0 0.00 1 080018300 OSAGE REHAB & HEALTH CARE CENTER 214.28 0 26 0.00 1 080021000 THE REHAB CENTER OF DES MOINES 1,173.39 0 56 0.00 1 080021500 ACCURA HEALTHCARE OF STANTON 5,210.04 0 31 1,477.90 1 080021800 IVY AT DAVENPORT 43.50 0 1 0.00 1 080023500 BETHANY LIFE 9,456.85 4 39 1,796.00 2 080027900 AZRIA HEALTH PRAIRIE RIDGE 17,296.69 0 79 8,828.61 1 080028900 NORWALK NURSING AND REHABILITATION 4,578.48 9 22 1,713.08 1 080029900 ACCURA HEALTHCARE OF SHENANDOAH 0.00 0 7 0.00 1 080066500 AZRIA HEALTH LONGVIEW 55,497.42 0 243 9,006.01 2 080067300 ASPIRE OF GOWRIE 8,538.64 0 31 0.00 1 080068500 URBANDALE HEALTH CARE CENTER 20,546.10 0 91 10,286.52 1 080069400 ELKADER CARE CENTER 717.71 0 28 0.00 1 080071900 HARMONY CEDAR RAPIDS 0.00 0 17 0.00 2 080079700 CROWN POINTE ESTATES CARE CENTER 12,165.38 0 61 6,030.76 1 080123300 FAITH LUTHERAN HOME 16,561.26 0 61 2,219.42 1 080142300 GOOD SAMARITAN SOCIETY-DAVENPORT 28,095.30 0 102 5,362.50 2 080148000 GOOD SAMARITAN SOCIETY-INDIANOLA 16,516.48 13 58 4,686.00 2 080150600 GOOD SAMARITAN SOCIETY-MANSON 23,380.63 0 91 0.00 1 080155500 GOOD SAMARITAN SOCIETY - ST ANSGAR 0.00 0 10 0.00 1 080194400 HOLY SPIRIT RETIREMENT HOME 10,605.54 0 40 642.24 2 080298300 OAKVIEW NURSING CENTER 6,201.08 0 31 1,717.87 1 080322100 SAVANNAH HEIGHTS 35,972.65 0 123 4,630.00 2 080377500 ST LUKE LUTHERAN HOME INC 14,393.80 0 77 1,407.72 2 080381700 STONEHILL CARE CENTER 0.00 0 8 0.00 1 080466600 NEW LONDON SPECIALTY CARE 0.00 0 4 0.00 1 080479900 WESTVIEW OF INDIANOLA CARE CENTER 16,300.65 0 62 4,785.24 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 8,472.60 0 30 0.00 1 080512700 ACCURA HEALTHCARE OF NEWTON EAST 0.00 0 7 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 48,573.78 0 194 4,402.90 3 080604200 IOWA VETERANS HOME 2,599,596.65 26 6,685 716,968.61 184 080734700 CARLISLE CARE CENTER FOR WELLNESS & 10,368.67 0 52 892.00 1 080791700 OAKWOOD SPECIALTY CARE 14,571.90 0 61 4,118.50 1 080792500 ATLANTIC SPECIALTY CARE 1,071.72 0 0 0.00 1 080794100 BEDFORD SPECIALTY CARE 7,543.96 0 35 1,130.00 2 080799000 CHEROKEE SPECIALTY CARE 105.31- 0 0 105.31 1 080802200 CORNING SPECIALTY CARE 8,232.67 0 31 0.00 1 080803000 CORRECTIONVILLE SPECIALTY CARE 11,609.65 0 91 11,427.00 1 080806300 ODEBOLT SPECIALTY CARE 4,618.52 0 52 1,769.44 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080811300 CRESTVIEW SPECIALTY CARE 2,090.42 0 9 505.00 1 080812100 DUBUQUE SPECIALTY CARE 5,720.00 0 20 0.00 1 080815400 HERITAGE SPECIALTY CARE 12,304.33 0 61 4,482.26 1 080816200 LAMONI SPECIALTY CARE 22,877.74 0 92 2,055.18 1 080817000 LANTERN PARK SPECIALTY CARE 22,019.40 0 78 0.00 1 080818800 LYON SPECIALTY CARE 5,963.05 0 31 741.01 1 080819600 MANLY SPECIALTY CARE 0.00 0 23 1,684.00 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 3,680.28 0 24 3,685.32 1 080824600 SOUTHERN HILLS SPECIALTY CARE 24,155.95 0 91 0.00 1 080832900 WESTWOOD SPECIALTY CARE 8,846.12 0 31 563.00 1 080913700 WESTBROOK ACRES 9,227.27 0 61 5,448.72 1 080923600 HIAWATHA CARE CENTER 17,984.07 0 92 8,202.81 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 63,222.12 11 79 0.00 1 TOTAL: 3,304,773.56 63 9,693 840,266.23 260 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 1,476.64 0 152 4,120.00 3 011170800 PARK PLACE 1,045.68 0 124 3,520.00 4 011515400 CEDAR VALLEY RANCH 301.42 0 31 840.00 1 014759500 RINGGOLD CO GROUP HOME 2,731.50 6 177 3,921.00 1 030025100 SCENIC ACRES 924.26 0 93 2,500.00 3 030030700 SUSAN HESPEN 331.69 0 31 809.73 1 030032800 RISE LTD 321.42 8 23 820.00 1 030039200 COMPREHENSIVE SYSTEMS 4,666.45 5 600 17,326.00 5 030053000 CEDAR VALLEY RANCH 4,083.24 8 333 8,472.38 11 030056100 PRIDE GROUP 3,361.78 4 281 7,131.92 10 030056600 PRAIRIE VIEW 171.42 0 31 970.00 1 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 1,165.10 0 155 4,542.00 5 030091900 PRIDE GROUP 1,457.10 3 166 4,765.48 6 030125900 NISHNA PRODUCTIONS RES COOR 779.05 11 51 1,503.79 2 030136600 RINGGOLD CO GROUP HOME 753.26 0 93 2,671.00 3 030190300 PENN CENTER INC 9,810.75 20 1,322 39,255.73 12 030193400 STEVEN RAINEY 928.97 0 27 65.17 1 030235000 PRIDE GROUP 649.80 2 88 2,664.00 2 030263200 HORIZONS UNLIMITED 612.84 1 61 1,670.00 2 030294900 DAVID GIOVANNONI 62.42 0 31 1,079.00 1 030302100 KEVIN BANWART 338.63 0 31 802.79 1 030304200 DONNA HENDERSON 0.00 0 5 184.10 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 181.42 1 30 960.00 1 030401800 ASHLIE RAGON 1,170.49 0 121 3,228.00 1 030409400 NEW HAMPTON GROUP HOME 827.79 0 91 2,494.00 1 030410700 CHATHAM OAKS 0.00 0 19 699.58 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 030459500 PRIDE GROUP 642.84 0 62 1,640.00 2 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 541.59 2 88 2,744.31 1 030464300 ABBE HEALTH 19,596.54 39 2,518 73,949.56 23 030475000 THE PRIDE GROUP 155.42 2 29 986.00 1 030475400 PRAIRIE VIEW MGMT 2,041.18 0 215 5,704.00 2 030476500 HILLCREST 262.70 0 30 814.00 1 030492000 COMP SYSTEMS 1,467.01 31 90 2,931.48 1 030493500 PRIDE GROUP 1,522.56 0 155 4,184.54 5 030497500 JAY BAKER 38.42 0 31 1,103.00 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 1,311.66 0 155 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 472.84 0 62 1,810.00 2 030568200 NANCY NAILL 1,574.49 0 121 2,824.00 1 030571800 EDWARD PARROTT 301.42 0 31 840.00 1 030578800 COUNTRY CARE 757.24 0 93 2,667.02 3 030587200 CEDAR VALLEY RANCH INC 448.84 2 60 1,834.00 2 030597500 SARAH KUNATH 1,141.42 0 31 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030606900 ABBE CENTER BUS OFFICE 5,312.47 13 657 19,212.78 6 030612900 HORIZONS UNLIMITED OF PAC INC 1,058.51 5 88 2,365.75 3 030614900 VERA FRENCH COMM MENTAL 1,782.69 0 217 6,207.25 7 030646400 HORIZONS UNLIMITED 1,765.15 0 124 2,800.53 4 030678600 NINTH STREET GROUP HOME 1,170.49 8 113 3,228.00 1 030679100 ABBE CENTER FOR COMMUNITY MENTAL 321.42 0 31 820.00 1 030679600 NORTH IA TRANSITION CENTER 0.00 0 7 257.74 1 030680100 PRIDE IV 408.84 0 62 1,874.00 2 030680600 ABBE CENTER FOR CMH 1,183.59 0 122 3,279.62 2 030685400 PRIDE GROUP @ PRIMGHAR 642.84 0 62 1,640.00 2 030745400 NISHNA PRODUCTIONS 420.04 1 61 1,862.80 2 032034100 HOPE HAVEN 497.20 0 60 1,712.00 1 034414300 REDWOOD COURT 1,845.60 0 180 4,782.00 3 034463000 TERRACE VIEW RESIDENTIAL 581.20 0 81 2,401.22 1 035497700 NORTH IOWA TRANS CENTER 321.42 0 31 820.00 1 035515600 COMP SYSTEMS 8,323.88 42 1,018 30,194.75 9 035565100 NITC 439.42 0 31 702.00 1 036348100 PARK PLACE FOR 544.84 0 62 1,738.00 2 036377000 COUNTRY CARE CENTER 1,773.05 0 124 2,792.63 4 036670800 BETH WYATT 326.70 4 26 750.00 1 036800100 MAINSTREAM LIVING 1,247.11 0 62 1,035.73 2 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 2,613.28 17 262 7,659.50 9 038899100 COMP SYSTEMS MARY A 1,090.49 5 116 3,308.00 1 039139100 HOPE HAVEN 1,138.40 0 120 3,280.00 2 039409800 PRIDE GROUP 321.42 0 31 820.00 1 039460100 PRIDE GROUP 321.42 0 31 820.00 1 040965600 JOAN ROUTH 206.42 0 31 935.00 1 TOTAL: 109,182.59 240 12,120 343,343.95 216 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 50,909.56 0 31 137.45 1 TOTAL: 50,909.56 0 31 137.45 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 04/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/27/24 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 27,916.20 0 60 0.00 1 088025200 COURAGE HOMES 14,079.58 0 31 0.00 1 088036900 PARK VIEW HOMES 22,664.46 0 62 668.00 2 088063300 BLUFF VIEW HOMES 14,253.80 0 31 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 26,158.98 6 52 0.00 2 088107800 WOODRIDGE HOUSE 14,420.27 0 31 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 23,216.21 0 31 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,442.59 0 31 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,359.77 0 31 1,082.82 1 088211800 CHILDSERVE HOMES KEYSTONE 14,376.44 3 28 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,442.59 0 31 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,398.49 2 29 0.00 1 TOTAL: 213,729.38 11 448 1,750.82 14 ** END OF REPORT **