IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 18,000.00 0 30 0.00 1 065004500 MERCYONE SIOUXLAND MEDICAL CENTER 0.00 0 0 0.00 1 065540700 SANFORD SENIOR CARE SHELDON 3,464.00 0 2 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 187,830.38 0 150 1,054.12 5 TOTAL: 209,294.38 0 182 1,054.12 8 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 11 0.00 1 080007600 SUNNY KNOLL CARE CENTRE 24,040.56 0 92 3,747.12 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,978.10 0 30 0.00 1 080021000 THE REHAB CENTER OF DES MOINES 561.85 0 29 0.00 1 080021800 IVY AT DAVENPORT 54.51 0 5 0.00 1 080024000 WINDMILL MANOR 1,468.70 0 13 1,912.21 1 080025900 PILLAR OF CEDAR VALLEY 10,637.91 0 78 0.00 2 080028900 NORWALK NURSING AND REHABILITATION 23,625.59 0 108 2,581.34 2 080029100 GRANGER NURSING & REHAB CENTER 1,972.34- 10 14 1,475.00- 1 080029300 ALTOONA NURSING & REHABILITATION 7,712.63 0 31 850.50 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 7,510.69 0 30 1,259.81 1 080034600 ARBOR COURT 11,980.77 0 62 3,438.14 2 080066500 AZRIA HEALTH LONGVIEW 20,846.57 0 83 4,075.01 3 080067300 ASPIRE OF GOWRIE 13,792.84 0 30 0.00 1 080067400 ASPIRE OF ESTHERVILLE 513.96 0 29 0.00 1 080070800 ENNOBLE NURSING AND REHAB 0.00 0 1 0.00 1 080071700 HARMONY DUBUQUE 53.00- 0 0 53.00 1 080071800 HARMONY DAVENPORT 7,056.37 0 30 1,835.03 1 080072000 HARMONY UTICA RIDGE 159.97 0 19 0.00 1 080136500 GLEN HAVEN VILLAGE 29,805.60 0 122 9,641.88 1 080194400 HOLY SPIRIT RETIREMENT HOME 8,104.50 0 30 0.00 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 17,755.42 0 72 3,095.70 3 080235500 LUTHERAN RETIREMENT HOME 26,383.29 0 92 0.00 1 080314800 PARKVIEW MANOR CARE CENTER 7,680.41 0 30 1,274.89 1 080322100 SAVANNAH HEIGHTS 11,417.62 0 30 0.00 1 080355100 SALEM LUTHERAN HOMES 16.19 0 1 0.00 1 080377500 ST LUKE LUTHERAN HOME INC 196.81 0 27 0.00 1 080378300 STACYVILLE COMMMUNITY NURSING HOME 0.00 0 20 1,070.37 1 080381700 STONEHILL CARE CENTER 63.59 0 23 0.00 2 080398100 THORNTON MANOR NURSING&CARE CENTER 0.00 0 16 0.00 1 080466600 NEW LONDON SPECIALTY CARE 0.00 0 9 0.00 1 080479900 WESTVIEW OF INDIANOLA CARE CENTER 9.00- 0 0 9.00 1 080482300 HALLMARK CARE CENTER 5,151.22 0 25 3,099.78 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 8,472.60 0 30 0.00 1 080512700 ACCURA HEALTHCARE OF NEWTON EAST 0.00 0 30 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 55,274.09 0 213 3,022.90 4 080547300 SUNNY VIEW CARE CENTER 40.00 0 12 0.00 1 080582000 CEDAR MANOR NURSING HOME 25,111.86 0 92 594.18 1 080604200 IOWA VETERANS HOME 2,442,742.20 33 5,809 573,068.85 197 080732100 FLEUR HEIGHTS CENTER FOR WELLNESS & 3,457.65 10 15 1,230.00 1 080734700 VIA OF CARLISLE 7,615.98 0 60 892.00 1 080736200 OELWEIN HEALTHCARE CENTER 6,561.21 0 31 2,079.11 1 080739600 EMMETSBURG CARE CENTER 1,819.74 2 6 0.00 1 080807100 CORYDON SPECIALTY CARE 13,352.47 0 57 1,793.00 1 080810500 CRESTON SPECIALTY CARE 0.00 0 14 0.00 1 080812100 DUBUQUE SPECIALTY CARE 0.00 0 14 0.00 1 080813900 DUNLAP SPECIALTY CARE 20,290.80 0 60 0.00 1 080815400 HERITAGE SPECIALTY CARE 327.16 0 27 1,879.72 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080816200 LAMONI SPECIALTY CARE 628.96 0 6 982.88 1 080818800 LYON SPECIALTY CARE 5,746.79 0 30 741.01 1 080821200 MECHANICSVILLE SPECIALTY CARE 13,827.30 0 60 1,276.50 1 080824600 SOUTHERN HILLS SPECIALTY CARE 2,961.97 0 11 0.00 1 080826100 NORTHCREST SPECIALTY CARE 16,582.00 0 60 3,078.80 1 080827900 RAVENWOOD SPECIALTY CARE 34,283.90 0 150 7,017.70 2 080859200 RISEN SON CHRISTIAN VILLAGE 0.00 0 20 0.00 1 080913700 WESTBROOK ACRES 3,225.64 0 25 2,798.36 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 26,228.40 20 33 0.00 1 080965700 HAPPY SIESTA NURSING HOME 8,528.41 0 31 0.00 1 TOTAL: 2,940,560.46 55 8,060 636,923.79 266 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 833.80 0 90 2,480.00 3 011170800 PARK PLACE 1,183.00 0 150 4,340.00 5 011515400 CEDAR VALLEY RANCH 1,791.12 0 116 2,480.00 2 030025100 SCENIC ACRES 813.80 0 90 2,500.00 3 030030700 SUSAN HESPEN 294.87 0 30 809.73 1 030032800 RISE LTD 284.60 8 22 820.00 1 030039200 COMPREHENSIVE SYSTEMS 1,122.00 2 148 4,401.00 5 030053000 CEDAR VALLEY RANCH 3,678.22 5 325 8,472.38 11 030056100 PRIDE GROUP 3,313.10 7 293 7,705.00 10 030056600 PRAIRIE VIEW 134.60 0 30 970.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 549.20 2 58 1,660.00 2 030067300 PARK PLACE 264.60 0 30 840.00 1 030070700 AREA RESIDENTIAL CARE 2,904.00 0 300 8,142.00 4 030084800 COUNTRY CARE CENTER CORP 403.76 0 60 1,805.44 2 030085500 CEDAR VALLEY RANCH 981.00 0 150 4,542.00 5 030086900 HILLCREST FAMILY SERVICES 1,081.51- 0 62 1,172.50- 1 030091900 PRIDE GROUP 1,492.81 4 175 5,071.00 5 030093900 ANDREW JACKSON CARE 2,094.60 0 152 3,360.68 3 030125900 NISHNA PRODUCTIONS RES COOR 430.60 4 26 674.00 1 030136600 RINGGOLD CO GROUP HOME 1,083.40 0 120 3,335.00 4 030190300 PENN CENTER INC 1,854.40 0 270 8,087.00 9 030193400 STEVEN RAINEY 96.43 8 22 1,008.17 1 030235000 PRIDE GROUP 284.60 0 50 1,537.80 2 030263200 HORIZONS UNLIMITED 539.20 0 60 1,670.00 2 030294900 DAVID GIOVANNONI 25.60 0 30 1,079.00 1 030302100 KEVIN BANWART 353.26 1 29 751.34 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 144.60 1 29 960.00 1 030382600 HANDICAPPED DEV CENTER 264.60 7 23 840.00 1 030401800 ASHLIE RAGON 284.60 0 30 820.00 1 030409400 NEW HAMPTON GROUP HOME 264.60 0 30 840.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 300.60 0 30 804.00 1 030425100 THOMAS FAULKNER 10.60 0 30 1,094.00 1 030459500 PRIDE GROUP 569.20 1 59 1,640.00 2 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 181.83 0 30 922.77 1 030464300 ABBE HEALTH 6,867.47 10 770 21,794.47 24 030475000 THE PRIDE GROUP 118.60 2 28 986.00 1 030475400 PRAIRIE VIEW MGMT 284.60 0 30 820.00 1 030492000 COMP SYSTEMS 317.73 5 25 786.87 1 030493500 PRIDE GROUP 1,338.46 0 150 4,184.54 5 030497500 JAY BAKER 1.60 0 30 1,103.00 1 030524800 HDC 1,983.48 0 214 5,896.00 4 030550500 JULIA LINNANE 264.60 0 30 840.00 1 030552100 VF SHERIDAN SPRINGS 1,001.21 0 120 3,417.19 4 030552700 SHERIDAN SPRINGS 1,127.56 0 150 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 399.20 0 60 1,810.00 2 030558200 SHELLEY FIEDLER 264.60 0 30 840.00 1 030568200 NANCY NAILL 387.60 0 30 717.00 1 030571300 BRENDA HENRY SCHREIBER 640.80 0 90 2,673.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030571800 EDWARD PARROTT 264.60 0 30 840.00 1 030578800 COUNTRY CARE 646.78 0 90 2,667.02 3 030587200 CEDAR VALLEY RANCH INC 375.20 0 60 1,834.00 2 030587400 ARCBEACON HILL RCF 442.80 0 90 2,871.00 1 030597500 SARAH KUNATH 1,104.60 0 30 0.00 1 030606900 ABBE CENTER BUS OFFICE 1,304.00 0 180 5,323.60 6 030612900 HORIZONS UNLIMITED OF PAC INC 1,232.65 3 117 3,185.75 4 030613600 ADELINE COMM. LIVING HOME 933.03 14 76 2,380.77 1 030614900 VERA FRENCH COMM MENTAL 1,524.95 2 208 6,207.25 7 030615300 BUNKER HILL COMMUNITY LIVING HOME 451.80 0 90 2,862.00 1 030625400 JUSTIN HAY 260.60 0 30 844.00 1 030646400 HORIZONS UNLIMITED 1,617.87 0 120 2,800.53 4 030678600 NINTH STREET GROUP HOME 284.60 0 60 1,924.60 2 030679100 ABBE CENTER FOR COMMUNITY MENTAL 1,084.42 0 161 4,843.60 2 030679300 HANDICAPPED DEV GRP HM #8 566.02 0 61 1,680.00 1 030680100 PRIDE IV 211.80 0 90 3,102.00 1 030680600 ABBE CENTER FOR CMH 793.80 13 77 2,520.00 1 030685400 PRIDE GROUP @ PRIMGHAR 569.20 0 60 1,640.00 2 030690000 KEYWAY COMMUNITY LIVING HOME 421.60 2 28 683.00 1 030745400 NISHNA PRODUCTIONS 912.42 0 121 3,542.80 3 034463000 TERRACE VIEW RESIDENTIAL 0.00 0 21 773.22 1 035379700 HERITAGE RESIDENCE 1,037.82 0 51 840.00 1 035497700 NORTH IOWA TRANS CENTER 0.00 0 1 36.82 1 035515600 COMP SYSTEMS 2,092.10 4 266 7,849.30 9 036348100 PARK PLACE FOR 471.20 0 60 1,738.00 2 036377000 COUNTRY CARE CENTER 1,625.77 0 120 2,792.63 4 036800100 MAINSTREAM LIVING 888.87 0 30 215.73 1 037594900 MOSAIC 310.60 0 30 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 1,148.26 0 304 9,846.00 1 038614400 RISE GROUP HOME 2,281.90 25 245 7,659.50 9 038899100 COMP SYSTEMS MARY A 264.60 0 30 840.00 1 039460100 PRIDE GROUP 284.60 3 27 820.00 1 040526600 ROBERT HEFFLEFINGER % ARC 91.20 8 52 2,118.00 1 040965600 JOAN ROUTH 169.60 0 30 935.00 1 089006400 PRIDE III 775.88 0 92 2,526.00 1 089501100 HILLCREST FAMILY SERVICES 752.63 0 62 1,501.38 1 TOTAL: 69,940.97 141 7,982 228,590.82 228 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 43,397.11 0 30 304.19 1 TOTAL: 43,397.11 0 30 304.19 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 05/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/25/24 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 13,693.50 3 27 0.00 1 088025200 COURAGE HOMES 13,625.40 0 30 0.00 1 088026000 HILLS AND DALES 42,685.20 0 90 0.00 1 088036900 PARK VIEW HOMES 21,911.80 0 60 668.00 2 088063300 BLUFF VIEW HOMES 13,794.00 0 30 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 26,872.05 15 45 0.00 2 088107800 WOODRIDGE HOUSE 13,955.10 0 30 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,162.90 0 30 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 13,976.70 0 30 0.00 1 088173000 HARMONY HOUSE HEALTH CARE CENTER 5,185.76- 0 0 5,185.76 1 088175500 TANAGER PLACE 133,364.82 4 280 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 12,925.10 0 30 1,051.60 1 088211800 CHILDSERVE HOMES KEYSTONE 13,954.65 1 29 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 13,932.60 2 28 0.00 1 TOTAL: 353,668.06 25 739 6,905.36 16 ** END OF REPORT **