IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 16,200.00 0 27 0.00 1 065500600 KNOXVILLE HOSPITAL AND CLINICS 0.00 0 2 0.00 1 065536500 HAMILTON COUNTY PUBLIC HOSPITAL 0.00 0 3 0.00 1 065569600 SHENANDOAH MEMORIAL HOSPITAL 0.00 0 6 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 261,268.22 3 210 1,054.72 7 TOTAL: 277,468.22 3 248 1,054.72 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080006300 CAREAGE HILLS REHAB & HEALTHCARE 773.26 0 0 773.26- 1 080006500 CLARION WELLNESS & REHAB CENTER 5,479.46 0 23 278.36 2 080006800 PARKVIEW MANOR 0.00 0 17 0.00 1 080010800 PREMIER ESTATES OF MUSCATINE 20,206.44 4 72 1,498.02 2 080017600 CASA DE PAZ HEALTH CARE CENTER 8,715.15 0 33 1,167.00 3 080017800 CEDAR FALLS HEALTH CARE CENTER 11,421.00 0 44 2,329.00 1 080019600 BISHOP DRUMM 7,609.60 0 29 0.00 1 080021800 IVY AT DAVENPORT 62.57 0 10 0.00 1 080022700 BETHANY LUTHERAN HOME 33,057.43 0 121 4,958.00 2 080024000 WINDMILL MANOR 0.00 0 0 0.00 1 080025900 PILLAR OF CEDAR VALLEY 10,238.40 0 60 0.00 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 0.00 0 27 0.00 1 080034600 ARBOR COURT 6,010.59 0 33 2,592.84 1 080036700 GOOD SAMARITAN SOCIETY-LE MARS 705.48 0 8 1,907.00 1 080048200 NEW ALDAYA LIFESCAPES 6,213.94 0 31 3,948.48 1 080065700 PINE ACRES REHAB AND CARE CENTER 7,453.32 0 30 1,418.28 1 080066500 AZRIA HEALTH LONGVIEW 7,030.45 0 96 3,250.01 2 080067300 ASPIRE OF GOWRIE 6,523.80 0 30 0.00 1 080067400 ASPIRE OF ESTHERVILLE 0.00 0 17 0.00 1 080081300 COMMUNITY CARE CENTER 6,406.77 0 31 0.00 1 080082100 CLARKSVILLE NURSING & REHAB CENTER 5,682.18 0 31 2,929.00 1 080123300 FAITH LUTHERAN HOME 22,808.11 0 91 4,449.37 1 080190200 HILLCREST HOME 54,074.58 0 212 11,006.74 3 080194400 HOLY SPIRIT RETIREMENT HOME 20,703.21 0 84 1,864.27 2 080228000 LUTHER MANOR RETIREMENT HOME 203.26 0 17 0.00 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 38,440.52 0 152 5,397.80 2 080322100 SAVANNAH HEIGHTS 9,822.00 0 30 0.00 1 080355100 SALEM LUTHERAN HOMES 7,294.60 0 31 1,537.61 2 080373400 ST FRANCIS MANOR 2,809.87 0 15 2,105.78 1 080377500 ST LUKE LUTHERAN HOME INC 196.81- 0 27 0.00 1 080381700 STONEHILL CARE CENTER 220.96 0 5 0.00 2 080393200 SUNRISE TERRACE NURSING & REHAB 16,046.05 0 61 0.00 1 080420300 WEST POINT CARE CENTER 8,317.30 0 31 0.00 1 080456700 SOUTHFIELD WELLNESS COMMUNITY 28,795.13 0 91 0.00 1 080466600 NEW LONDON SPECIALTY CARE 1,932.08 0 8 0.00 1 080478100 REHABILITATION CENTER OF HAMPTON 0.00 0 13 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 8,568.20 0 53 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 29,831.90 0 120 3,022.90 4 080531700 STATE CENTER SPECIALTY CARE 13,655.10 0 90 7,530.00 1 080532500 MONTEZUMA SPECIALTY CARE 4,645.22 0 31 4,112.59 1 080604200 IOWA VETERANS HOME 2,316,669.87 81 5,472 478,874.89 175 080708100 ST LUKES HELEN G NASSIF TRANSITIONA 0.00 0 18 0.00 1 080734700 VIA OF CARLISLE 7,507.10 0 30 892.00 1 080738800 ABCM REHAB CENTER OF INDEPENDENCE 0.00 0 0 0.00 1 080739600 EMMETSBURG CARE CENTER 1,069.12 0 0 1,069.12- 1 080789100 FELLOWSHIP VILLAGE 13,309.94 0 83 12,435.00 1 080791700 OAKWOOD SPECIALTY CARE 14,425.70 0 60 3,603.10 1 080800600 AVOCA SPECIALTY CARE 0.00 0 21 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080812100 DUBUQUE SPECIALTY CARE 5,028.07 0 38 5,052.65 3 080818800 LYON SPECIALTY CARE 5,746.79 0 30 741.01 1 080820400 SOUTHRIDGE SPECIALTY CARE 14,769.75 0 61 1,563.00 2 080825300 PARKRIDGE SPECIALTY CARE 25,458.19 0 91 6,855.00 1 080826100 NORTHCREST SPECIALTY CARE 35.83 0 9 0.00 1 080832900 WESTWOOD SPECIALTY CARE 2,934.68 0 18 2,450.20 1 TOTAL: 2,818,516.16 85 7,782 577,927.52 246 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 833.80 0 90 2,480.00 3 011170800 PARK PLACE 1,183.00 0 150 4,340.00 5 011515400 CEDAR VALLEY RANCH 264.60 0 30 840.00 1 011623600 ANDREW JACKSON CARE 1,144.40 0 150 4,378.60 5 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 12 18 820.00 1 030039200 COMPREHENSIVE SYSTEMS 1,122.00 4 146 4,401.00 5 030053000 CEDAR VALLEY RANCH 4,248.42 7 383 10,111.38 13 030056100 PRIDE GROUP 46.18 0 1 83.00- 2 030061600 MEDIAPOLIS CARE FACILITY 284.60 0 30 820.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 931.80 4 86 2,382.00 3 030067300 PARK PLACE 264.60 0 30 840.00 1 030084800 COUNTRY CARE CENTER CORP 369.32 0 60 1,839.88 2 030085500 CEDAR VALLEY RANCH 904.40 0 120 3,514.00 4 030086900 HILLCREST FAMILY SERVICES 1,233.82 0 151 4,326.00 5 030093900 ANDREW JACKSON CARE 873.78 0 210 6,886.32 8 030125900 NISHNA PRODUCTIONS RES COOR 430.60 6 24 674.00 1 030136600 RINGGOLD CO GROUP HOME 1,083.40 0 120 3,335.00 4 030252000 HOWARD COLE 235.60 0 30 869.00 1 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 237.63 1 29 866.97 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 130.34 1 29 974.26 1 030339500 HILLCREST FAMILY SERVICES 111.60 0 30 993.00 1 030382600 HANDICAPPED DEV CENTER 264.60 0 30 840.00 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 030448600 BLAKE GRIGGS 0.00 0 2 73.64 1 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 181.83 0 30 922.77 1 030475400 PRAIRIE VIEW MGMT 1,037.82 0 51 840.00 1 030476500 HILLCREST 598.40 0 197 6,655.14 7 030481800 HILLCREST 890.62 0 91 2,460.00 2 030497500 JAY BAKER 1.60 0 30 1,103.00 1 030524800 HDC 813.80 0 90 2,500.00 3 030550500 JULIA LINNANE 264.60 0 30 840.00 1 030552100 VF SHERIDAN SPRINGS 1,076.85 0 120 3,341.55 4 030552700 SHERIDAN SPRINGS 1,127.56 7 143 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 399.20 0 60 1,810.00 2 030568200 NANCY NAILL 387.60 0 30 717.00 1 030571800 EDWARD PARROTT 264.60 0 30 840.00 1 030578800 COUNTRY CARE 425.86 0 84 2,667.02 3 030587200 CEDAR VALLEY RANCH INC 375.20 0 60 1,834.00 2 030612900 HORIZONS UNLIMITED OF PAC INC 151.73 6 5 188.55- 4 030614900 VERA FRENCH COMM MENTAL 1,444.95 1 209 6,287.25 7 030625400 JUSTIN HAY 260.60 0 30 844.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030646400 HORIZONS UNLIMITED 1,521.87 0 120 2,896.53 4 030678600 NINTH STREET GROUP HOME 284.60 5 55 1,924.60 2 030679300 HANDICAPPED DEV GRP HM #8 264.60 0 30 840.00 1 030690000 KEYWAY COMMUNITY LIVING HOME 1,724.51 5 187 5,278.90 1 030690100 IMAGINE THE POSSIBILITIES INC 598.93 0 30 505.67 1 030745400 NISHNA PRODUCTIONS 346.40 0 60 1,862.80 2 032034100 HOPE HAVEN 248.60 0 30 856.00 1 034414300 REDWOOD COURT 419.60 0 34 832.28 3 035515600 COMP SYSTEMS 1,617.09 0 210 6,115.11 7 036348100 PARK PLACE FOR 281.27- 0 32 896.97- 2 036377000 COUNTRY CARE CENTER 1,625.77 0 120 2,792.63 4 037594900 MOSAIC 310.60 0 30 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 284.60 0 30 820.00 1 038614400 RISE GROUP HOME 2,076.89 20 188 5,610.50 9 039139100 HOPE HAVEN 569.20 14 46 1,640.00 2 040965600 JOAN ROUTH 169.60 0 30 935.00 1 089002300 IMAGINE THE POSSIBILITIES INC 1,210.61 0 61 978.68 1 089360200 HORIZONS UNLIMITED OF PAC INC 1,552.42 12 109 2,902.80 1 089404800 RISE GROUP HOME 29.01 4 58 2,225.00 1 089448500 PRIDE GROUP @ PRIDE 1 7.91 0 31 1,133.51 1 089522700 PARK PLACE 516.35 0 92 2,871.09 1 TOTAL: 43,817.67 97 5,086 146,925.53 174 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 43,351.83 0 30 349.47 1 TOTAL: 43,351.83 0 30 349.47 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 07/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 07/27/24 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 13,958.10 0 30 0.00 1 088036900 PARK VIEW HOMES 21,911.80 0 60 668.00 2 088068200 PROGRESS INDUSTRIES WEST 26,575.29 5 56 1,786.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 13,511.24 4 26 0.00 1 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 088175500 TANAGER PLACE 43,152.34 2 89 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 12,893.88 0 30 1,082.82 1 088211800 CHILDSERVE HOMES KEYSTONE 13,932.60 2 28 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 13,976.70 0 30 0.00 1 TOTAL: 212,006.65 13 439 3,536.82 12 ** END OF REPORT **