IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 065004500 MERCYONE SIOUXLAND MEDICAL CENTER 13,397.40 0 18 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 270,082.83 3 217 1,054.72 7 TOTAL: 283,480.23 3 235 1,054.72 8 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 15,280.18 0 61 4,249.58 1 080006900 GREATER SOUTHSIDE HEALTH AND REHABI 7,443.95 0 30 2,113.45 1 080007900 ELMWOOD CARE CENTER 23,169.34 0 91 4,691.00 1 080008900 BETTENDORF HEALTH CARE CENTER 49,144.32 0 162 0.00 1 080011700 GOLDEN AGE CARE CENTER 3,321.36 0 20 1,724.04 1 080017300 LENOX CARE CENTER 0.00 0 0 0.00 1 080017500 DENISON CARE CENTER 24,406.20 0 91 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 9,277.37 0 31 0.00 1 080018300 OSAGE REHAB & HEALTH CARE CENTER 7,020.12 0 30 1,651.08 1 080019600 BISHOP DRUMM 27,090.68 0 109 0.00 2 080022700 BETHANY LUTHERAN HOME 9,858.93 0 31 0.00 1 080023000 ACCURA HEALTHCARE OF MARSHALLTOWN 14,586.13 0 91 8,977.41 1 080024000 WINDMILL MANOR 0.00 0 0 0.00 1 080025900 PILLAR OF CEDAR VALLEY 5,289.84 0 31 0.00 1 080028500 MONTROSE HEALTH CENTER 0.00 0 30 0.00 1 080034600 ARBOR COURT 29.12 0 32 0.00 1 080066500 AZRIA HEALTH LONGVIEW 13,834.77 0 56 2,079.01 3 080069100 ACCURA HEALTHCARE OF CASCADE 894.33 0 3 0.00 1 080069600 MOUNT CARMEL BLUFFS 27,963.39 0 91 0.00 1 080071500 HARMONY WATERLOO 0.00 0 10 1,007.00 1 080071800 HARMONY DAVENPORT 19,119.66 0 85 6,155.10 2 080096100 DAVENPORT LUTHERAN HOME 2,827.24 0 14 868.34 1 080145600 GOOD SAMARITAN SOCIETY-FOREST CITY 9,341.57 0 56 4,539.50 2 080154800 GOOD SAMARITAN SOCIETY RED OAK 783.78 0 3 0.00 1 080180300 COMMUNITY MEMORIAL HEALTH CENTER 0.00 0 6 0.00 1 080194400 HOLY SPIRIT RETIREMENT HOME 8,374.65 0 31 0.00 1 080211600 KANAWHA COMMUNITY HOME 3,824.32 15 21 1,235.00 1 080237100 MADRID HOME FOR THE AGING 18,922.47 0 70 4,668.93 3 080247000 MAPLE CREST MANOR 13,690.50 0 58 2,094.20 1 080314800 PARKVIEW MANOR CARE CENTER 5,698.10 0 31 3,637.24 1 080322100 SAVANNAH HEIGHTS 10,149.40 0 31 0.00 1 080333800 GRAND JIVANTE 2,055.14 0 16 1,718.78 1 080373400 ST FRANCIS MANOR 8,093.32 0 31 1,931.77 1 080381700 STONEHILL CARE CENTER 53.11 0 0 0.00 1 080418700 WESLEY ON GRAND 9,608.84 0 31 1,117.16 1 080466600 NEW LONDON SPECIALTY CARE 17,400.86 0 78 0.00 2 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,905.93 0 31 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 31,141.96 0 125 2,835.90 4 080604200 IOWA VETERANS HOME 2,609,560.81 53 6,148 523,278.43 181 080734700 VIA OF CARLISLE 7,787.07 0 31 892.00 1 080804800 KINGSLEY SPECIALTY CARE 5,867.12 0 36 2,644.00 1 080813900 DUNLAP SPECIALTY CARE 0.00 0 7 0.00 1 080815400 HERITAGE SPECIALTY CARE 6,008.87 0 31 2,542.79 2 080816200 LAMONI SPECIALTY CARE 3,872.63 0 10 1,186.23- 2 080818800 LYON SPECIALTY CARE 5,963.05 0 31 741.01 1 080819600 MANLY SPECIALTY CARE 5,340.56 0 26 1,304.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 2,238.53 0 13 1,204.00 1 080824600 SOUTHERN HILLS SPECIALTY CARE 6,238.37 0 31 2,109.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080829500 STRATFORD SPECIALTY CARE 1,400.50 0 5 0.00 1 080866700 GRANDVIEW HEIGHTS 22,097.85 0 91 4,508.73 1 080879000 THE VILLAGE 9,880.63 0 31 0.00 1 TOTAL: 3,093,856.87 68 8,209 595,332.22 244 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 347.42- 0 31 794.00- 1 011515400 CEDAR VALLEY RANCH 301.42 0 31 840.00 1 030019700 HOPE HAVEN ADMIN 401.92 0 56 1,660.00 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 6 25 820.00 1 030053000 CEDAR VALLEY RANCH 4,727.08 6 397 10,111.38 13 030056100 PRIDE GROUP 3,845.22 7 499 14,756.87 8 030061800 PENN CENTER INC 301.42 6 25 840.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 720.84 5 71 2,077.48 3 030070700 AREA RESIDENTIAL CARE 698.40 0 120 3,720.00 4 030084800 COUNTRY CARE CENTER CORP 228.54 0 56 1,833.38 2 030085500 CEDAR VALLEY RANCH 1,241.70 0 185 5,570.00 5 030091900 PRIDE GROUP 4,013.00 10 432 12,146.12 8 030125900 NISHNA PRODUCTIONS RES COOR 467.42 9 22 674.00 1 030136600 RINGGOLD CO GROUP HOME 753.26 0 109 3,260.12 4 030235000 PRIDE GROUP 606.02 0 61 1,640.00 1 030252000 HOWARD COLE 272.42 0 31 869.00 1 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 627.71- 3 58 1,618.31- 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 167.16 1 30 974.26 1 030382600 HANDICAPPED DEV CENTER 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 030459500 PRIDE GROUP 1,533.46 2 151 4,100.00 3 030475000 THE PRIDE GROUP 274.02 4 57 1,972.00 1 030476500 HILLCREST 3,320.40 6 267 6,618.00 1 030487400 THE PRIDE GROUP 436.01 0 62 1,818.00 2 030493500 PRIDE GROUP 2,559.60 0 274 7,529.08 5 030497500 JAY BAKER 38.42 0 31 1,103.00 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 5 150 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 472.84 1 61 1,810.00 2 030558200 SHELLEY FIEDLER 3,076.75 1 334 9,058.00 1 030571300 BRENDA HENRY SCHREIBER 2,103.48 0 275 7,823.00 1 030578800 COUNTRY CARE 428.32 0 62 1,854.52 2 030587200 CEDAR VALLEY RANCH INC 448.84 0 62 1,834.00 2 030587400 ARCBEACON HILL RCF 147.60 0 30 957.00 1 030597500 SARAH KUNATH 241.19 0 61 1,976.00 1 030612900 HORIZONS UNLIMITED OF PAC INC 1,474.23 5 119 3,091.45 4 030613600 ADELINE COMM. LIVING HOME 478.51 2 28 626.09 1 030614900 VERA FRENCH COMM MENTAL 1,522.52 0 207 6,099.22 7 030615300 BUNKER HILL COMMUNITY LIVING HOME 150.60 0 30 954.00 1 030646400 HORIZONS UNLIMITED 1,669.15 0 124 2,896.53 4 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030679300 HANDICAPPED DEV GRP HM #8 301.42 0 31 840.00 1 030680100 PRIDE IV 442.62 1 99 3,239.38 2 030685400 PRIDE GROUP @ PRIMGHAR 606.02 0 61 1,640.00 1 030690000 KEYWAY COMMUNITY LIVING HOME 706.20 3 57 1,503.00 2 030690100 IMAGINE THE POSSIBILITIES INC 635.75 0 31 505.67 1 030745400 NISHNA PRODUCTIONS 420.04 0 62 1,862.80 2 032034100 HOPE HAVEN 285.42 0 31 856.00 1 034414300 REDWOOD COURT 456.42 0 31 685.00 1 036377000 COUNTRY CARE CENTER 1,773.05 0 124 2,792.63 4 036800100 MAINSTREAM LIVING 606.02 0 61 1,640.00 1 037611100 PARTNERSHIP FOR PROGRESS 321.42 0 31 820.00 1 038258000 BREESE REST HOME 1,076.04 0 122 3,416.00 1 038614400 RISE GROUP HOME 1,421.26 10 83 2,003.00 6 039139100 HOPE HAVEN 642.84 0 62 1,640.00 2 039409800 PRIDE GROUP 382.18 0 64 1,916.64 2 039460100 PRIDE GROUP 67.36 0 24 794.00 1 040965600 JOAN ROUTH 206.42 0 31 935.00 1 089360200 HORIZONS UNLIMITED OF PAC INC 1,301.87 11 81 2,085.57 1 089404800 RISE GROUP HOME 37.26 5 88 3,387.00 1 089448500 PRIDE GROUP @ PRIDE 1 0.00 0 61 2,246.02 1 089522700 PARK PLACE 85.57 0 31 1,055.85 1 TOTAL: 57,566.43 106 6,360 179,717.47 158 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 43,520.39 0 31 392.97 1 TOTAL: 43,520.39 0 31 392.97 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 08/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/24/24 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 14,711.36 0 31 0.00 1 088063300 BLUFF VIEW HOMES 13,794.00 0 30 0.00 1 088068200 PROGRESS INDUSTRIES WEST 65,256.17 15 134 3,572.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,968.33 0 31 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,588.60 0 31 0.00 1 088175500 TANAGER PLACE 14,900.14 1 30 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,505.78 0 31 1,082.82 1 088211800 CHILDSERVE HOMES KEYSTONE 14,521.76 3 28 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,588.60 0 31 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,499.48 4 27 0.00 1 TOTAL: 205,334.22 23 404 4,654.82 10 ** END OF REPORT **