IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 065518300 FRANKLIN GENERAL HOSPITAL 0.00 0 4 0.00 1 065562100 GREATER COMMUNITY HOSPITAL 2,652.00 0 33 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 380,340.96 2 304 1,054.72 7 TOTAL: 401,592.96 2 372 1,054.72 10 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080004200 OAKLAND MANOR 27,486.45 0 85 0.00 1 080007900 ELMWOOD CARE CENTER 0.00 0 39 909.00 1 080008900 BETTENDORF HEALTH CARE CENTER 4,247.04 0 14 0.00 1 080011700 GOLDEN AGE CARE CENTER 13,310.39 0 62 2,397.00 1 080011800 WESTVIEW ACRES CARE CENTER 6,061.10 0 31 1,398.43 1 080017400 GARDEN VIEW CARE CENTER 2,325.50 0 10 444.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 9,277.37 0 31 0.00 1 080018300 OSAGE REHAB & HEALTH CARE CENTER 21,360.53 0 73 0.00 1 080021400 REHABILITATION CENTER OF LISBON 39,564.40 0 123 3,750.16 3 080025900 PILLAR OF CEDAR VALLEY 5,289.84 0 31 0.00 1 080027000 WESTWING PLACE 555.38 0 2 0.00 1 080028600 BIRKWOOD VILLAGE OF FORT MADISON 38.81 0 1 0.00 1 080066500 AZRIA HEALTH LONGVIEW 7,690.30 0 60 2,079.01 2 080066600 AZRIA HEALTH ROSE VISTA 24,031.01 0 97 4,713.00 2 080066800 SILVER OAK NURSING & REHABILITATION 953.58 0 3 0.00 1 080067300 ASPIRE OF GOWRIE 8,538.64 0 31 0.00 1 080067400 ASPIRE OF ESTHERVILLE 350.56 0 28 0.00 1 080069700 PRESTIGE CARE CENTER FAIRFIELD 1,280.69 0 5 42.61 1 080072000 HARMONY UTICA RIDGE 96.72 0 11 0.00 1 080081300 COMMUNITY CARE CENTER 18,843.44 0 92 0.00 1 080082100 CLARKSVILLE NURSING & REHAB CENTER 6,161.91 0 30 2,171.49 1 080107600 EASTERN STAR MASONIC HOME 26,780.34 0 91 2,602.65 1 080119100 WESTHAVEN COMMUNITY 21,749.63 0 91 3,668.48 2 080140700 GOOD NEIGHBOR HOME 522.57 0 22 0.00 1 080184500 HERITAGE HOUSE 570.60 0 0 0.00 1 080228000 LUTHER MANOR RETIREMENT HOME 22,630.56 0 86 1,710.88 2 080322100 SAVANNAH HEIGHTS 10,149.40 0 31 0.00 1 080374200 ST ANTHONY REGIONAL HOSPITAL 18,389.20 0 60 1,410.20 1 080381700 STONEHILL CARE CENTER 300.89 0 0 0.00 2 080479900 WESTVIEW OF INDIANOLA CARE CENTER 503.70 0 0 503.70- 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 8,755.02 0 31 0.00 1 080514300 ACCURA HEALTHCARE OF CHEROKEE 11,414.36 0 62 3,563.91 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 30,927.06 0 124 3,022.90 4 080604200 IOWA VETERANS HOME 2,461,251.51 74 5,820 507,890.30 177 080734700 VIA OF CARLISLE 14,496.51 6 55 892.00 2 080739600 EMMETSBURG CARE CENTER 7,726.29 0 29 1,069.12 1 080807100 CORYDON SPECIALTY CARE 9,323.34 0 50 3,962.16 1 080811300 CRESTVIEW SPECIALTY CARE 23,260.57 0 101 6,005.19 2 080813900 DUNLAP SPECIALTY CARE 0.00 0 14 0.00 1 080818800 LYON SPECIALTY CARE 5,963.05 0 31 741.01 1 080820400 SOUTHRIDGE SPECIALTY CARE 81,870.68 0 336 7,643.50 2 080826100 NORTHCREST SPECIALTY CARE 29,855.77 0 91 0.00 1 080827900 RAVENWOOD SPECIALTY CARE 20,818.17 0 92 4,526.76 1 080828700 RIDGEWOOD SPECIALTY CARE 13,283.32 0 65 1,585.33 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 1,600.56 0 2 0.00 1 TOTAL: 3,019,606.76 80 8,143 567,695.39 234 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 944.26 0 93 2,480.00 3 011170800 PARK PLACE 1,367.10 0 155 4,340.00 5 011515400 CEDAR VALLEY RANCH 622.84 1 61 1,660.00 2 011623600 ANDREW JACKSON CARE 8,749.27 0 1,096 31,292.97 6 030019700 HOPE HAVEN ADMIN 2,341.25 0 244 6,614.00 2 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 12 19 820.00 1 030039200 COMPREHENSIVE SYSTEMS 1,306.10 0 155 4,401.00 5 030053000 CEDAR VALLEY RANCH 10,005.87 27 833 21,459.38 13 030056100 PRIDE GROUP 2,191.53 0 248 6,911.00 8 030056600 PRAIRIE VIEW 740.62 0 105 3,125.48 2 030061600 MEDIAPOLIS CARE FACILITY 2,437.72 0 246 6,620.00 3 030061800 PENN CENTER INC 1,228.86 1 122 3,300.00 2 030064600 NORTH IOWA TRANSITIONAL CENTER 1,192.04 2 120 3,300.00 3 030067300 PARK PLACE 301.42 0 31 840.00 1 030070700 AREA RESIDENTIAL CARE 2,561.94 1 216 5,428.00 4 030071800 MARGARET MILLER 253.78 0 29 814.00 1 030084800 COUNTRY CARE CENTER CORP 442.96 0 62 1,839.88 2 030085500 CEDAR VALLEY RANCH 1,165.10 1 154 4,542.00 5 030086900 HILLCREST FAMILY SERVICES 301.42 0 31 840.00 1 030091900 PRIDE GROUP 1,778.52 8 178 5,070.00 6 030093900 ANDREW JACKSON CARE 12,905.53 0 1,610 46,005.46 8 030123700 MICHAEL GIVANS 867.44 0 92 2,520.00 1 030125900 NISHNA PRODUCTIONS RES COOR 467.42 5 26 674.00 1 030136600 RINGGOLD CO GROUP HOME 1,230.68 6 118 3,335.00 4 030190300 PENN CENTER INC 2,210.20 0 327 9,829.94 10 030193400 STEVEN RAINEY 133.25 18 13 1,008.17 1 030218500 MIKE HAMLETT % BRYCE HAMLETT 242.71 0 92 3,088.00 1 030235000 PRIDE GROUP 321.42 0 31 820.00 1 030252000 HOWARD COLE 1,523.23 0 183 5,186.00 1 030263200 HORIZONS UNLIMITED 612.84 0 62 1,670.00 2 030294900 DAVID GIOVANNONI 62.42 0 31 1,079.00 1 030302100 KEVIN BANWART 390.08 2 29 751.34 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 181.42 1 30 960.00 1 030382600 HANDICAPPED DEV CENTER 602.84 18 44 1,680.00 1 030401800 ASHLIE RAGON 321.42 0 31 820.00 1 030409400 NEW HAMPTON GROUP HOME 301.42 0 31 840.00 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 030448600 BLAKE GRIGGS 301.42 0 31 840.00 1 030459500 PRIDE GROUP 642.84 2 60 1,640.00 2 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 218.65 0 31 922.77 1 030464300 ABBE HEALTH 6,184.63 6 659 18,300.67 21 030475000 THE PRIDE GROUP 155.42 0 31 986.00 1 030475400 PRAIRIE VIEW MGMT 921.43 0 113 3,210.40 3 030476500 HILLCREST 321.42 0 31 820.00 1 030492000 COMP SYSTEMS 354.55 4 27 786.87 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030492900 NORTH IA TRANSITION CENT 1,141.42 2 29 0.00 1 030493500 PRIDE GROUP 1,522.56 0 155 4,184.54 5 030497500 JAY BAKER 38.42 0 31 1,103.00 1 030499600 EPIC GROUP HOME 381.20 0 60 1,828.00 1 030524800 HDC 924.26 0 93 2,500.00 3 030550500 JULIA LINNANE 301.42 0 31 840.00 1 030552100 VF SHERIDAN SPRINGS 1,224.13 2 122 3,341.55 4 030552700 SHERIDAN SPRINGS 1,311.66 13 142 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 472.84 0 62 1,810.00 2 030558200 SHELLEY FIEDLER 301.42 0 31 840.00 1 030568200 NANCY NAILL 424.42 0 31 717.00 1 030571300 BRENDA HENRY SCHREIBER 500.84 0 62 1,782.00 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 0 62 1,834.00 2 030587400 ARCBEACON HILL RCF 368.84 0 62 1,914.00 1 030597500 SARAH KUNATH 278.01 0 62 1,976.00 1 030606900 ABBE CENTER BUS OFFICE 1,264.10 4 151 4,443.00 5 030612900 HORIZONS UNLIMITED OF PAC INC 1,379.93 4 120 3,185.75 4 030613600 ADELINE COMM. LIVING HOME 863.16 7 55 1,419.68 1 030614900 VERA FRENCH COMM MENTAL 1,782.69 6 211 6,207.25 7 030615300 BUNKER HILL COMMUNITY LIVING HOME 374.84 0 62 1,908.00 1 030625400 JUSTIN HAY 297.42 0 31 844.00 1 030646400 HORIZONS UNLIMITED 1,669.15 0 124 2,896.53 4 030678600 NINTH STREET GROUP HOME 340.84 5 57 1,942.00 2 030679100 ABBE CENTER FOR COMMUNITY MENTAL 351.84 0 62 1,931.00 2 030679300 HANDICAPPED DEV GRP HM #8 301.42 0 31 840.00 1 030680100 PRIDE IV 673.44 0 92 2,714.00 2 030680600 ABBE CENTER FOR CMH 301.42 6 25 840.00 1 030685300 COUNTRY CARE CENTER CORP 1,279.51 0 335 10,885.00 1 030685400 PRIDE GROUP @ PRIMGHAR 321.42 0 37 1,040.92 2 030690000 KEYWAY COMMUNITY LIVING HOME 458.42 2 29 683.00 1 030690100 IMAGINE THE POSSIBILITIES INC 3,691.54 0 183 3,017.69 1 030745400 NISHNA PRODUCTIONS 721.46 4 89 2,702.80 3 032034100 HOPE HAVEN 534.02 0 61 1,712.00 1 034414300 REDWOOD COURT 1,475.88 0 183 5,262.18 3 035515600 COMP SYSTEMS 2,359.67 8 271 7,913.11 9 035713700 RONALD BRUCE 396.44 0 92 2,991.00 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 036800100 MAINSTREAM LIVING 925.69 0 31 215.73 1 037594900 MOSAIC 347.42 0 31 794.00 1 038258000 BREESE REST HOME 1,325.91 0 152 4,214.00 1 038614400 RISE GROUP HOME 2,546.28 30 249 7,726.50 9 038899100 COMP SYSTEMS MARY A 301.42 1 30 840.00 1 039096300 EXCEPTIONAL PERSONS INC 529.20 0 60 1,680.00 1 039139100 HOPE HAVEN 1,212.04 0 122 3,280.00 2 039409800 PRIDE GROUP 606.02 0 61 1,640.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 039460100 PRIDE GROUP 0.00 0 20 736.40 1 040526600 ROBERT HEFFLEFINGER % ARC 82.42 6 39 1,574.48 1 040965600 JOAN ROUTH 206.42 0 31 935.00 1 041207200 EXCEPTIONAL PERSONS INC 529.20 0 60 1,680.00 1 TOTAL: 115,836.95 215 12,649 356,477.26 262 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 44,817.61 0 31 340.40 1 TOTAL: 44,817.61 0 31 340.40 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 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 14,246.97 2 29 0.00 1 088025200 COURAGE HOMES 13,993.29 1 30 0.00 1 088026000 HILLS AND DALES 14,702.68 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 56,008.35 9 115 0.00 2 088107800 WOODRIDGE HOUSE 14,420.27 0 31 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 37,417.96 7 24 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,442.59 0 31 0.00 1 088175500 TANAGER PLACE 14,760.34 0 31 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,359.77 0 31 1,082.82 1 088211800 CHILDSERVE HOMES KEYSTONE 14,420.54 1 30 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,442.59 0 31 0.00 1 TOTAL: 259,133.61 20 507 1,750.82 15 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 8 AS OF 06/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 06/22/24 BILLING DOCUMENTS REPORT ICF PAYMENT SUMMARY BY VENDOR PROVIDER TYPE: 52 NURSING FACILITY - INT DISABLE VENDOR BED OTHER CLIENT TOTAL NUMBER VENDOR NAME PAYMENT HOLD DAYS DAYS PARTICIPATION RECIPIENTS --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 085000100 SE IOWA BEHAVIORAL HEALTH CARE CTR 3,542.05 0 14 728.23 1 TOTAL: 3,542.05 0 14 728.23 1 ** END OF REPORT **