IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 065508400 HUMBOLDT CO MEMORIAL HOSP 0.00 0 6 0.00 1 065522500 GRAPE COMMUNITY HOSPITAL 0.00 0 7 0.00 1 065536500 HAMILTON COUNTY PUBLIC HOSPITAL 0.00 0 21 0.00 1 065562100 GREATER COMMUNITY HOSPITAL 3,910.36 0 2 0.00 1 065569600 SHENANDOAH MEMORIAL HOSPITAL 0.00 0 2 0.00 1 065572000 DELAWARE COUNTY MEMORIAL HOSPITAL 36,487.78 0 14 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 376,412.26 4 302 1,054.72 7 TOTAL: 435,410.40 4 385 1,054.72 14 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 22,411.20 0 70 0.00 1 080006900 GREATER SOUTHSIDE HEALTH AND REHABI 8,641.68 0 31 1,234.30 1 080008100 LAURENS CARE CENTER 77.93 0 13 0.00 1 080008900 BETTENDORF HEALTH CARE CENTER 11,332.97 0 47 2,924.95 2 080009300 THE ALVERNO HEALTH CARE FACILITY 7,765.70 0 30 1,207.00 1 080010800 PREMIER ESTATES OF MUSCATINE 12,264.33 0 39 0.00 1 080010900 PREMIER ESTATES OF TOLEDO 13,501.69 0 47 0.00 1 080012500 ZEARING HEALTH CARE CENTER LLC 77,270.86 0 360 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 9,277.37 0 31 0.00 1 080021800 IVY AT DAVENPORT 19.07 0 1 0.00 3 080023000 ACCURA HEALTHCARE OF MARSHALLTOWN 4,939.62 0 19 0.00 1 080025900 PILLAR OF CEDAR VALLEY 5,289.84 0 31 0.00 1 080029000 REGENCY PARK NURSING AND REHABILITA 5,534.34 0 30 1,721.46 1 080029100 GRANGER NURSING & REHAB CENTER 16,678.16 0 61 2,754.00 2 080029400 UNIVERSITY PARK NURSING & REHAB CEN 26,682.76 0 92 0.00 1 080034600 ARBOR COURT 542.55 0 60 0.00 1 080065700 PINE ACRES REHAB AND CARE CENTER 0.00 0 42 0.00 1 080066500 AZRIA HEALTH LONGVIEW 12,261.19 0 81 2,079.01 3 080071600 HARMONY WEST DES MOINES 5,901.52 0 28 2,964.40 1 080143100 GOOD SAMARITAN SOCIETY-ESTHERVILLE 23,260.62 0 92 2,519.62 1 080145600 GOOD SAMARITAN SOCIETY-FOREST CITY 13,433.16 4 88 8,212.20 1 080147200 GOOD SAMARITAN SOCIETY-HOLSTEIN 0.00 0 8 913.00 1 080150600 GOOD SAMARITAN SOCIETY-MANSON 9,633.00 0 40 553.00 2 080152200 GOOD SAMARITAN SOCIETY-OTTUMWA 19,063.66 0 91 7,516.53 1 080154800 GOOD SAMARITAN SOCIETY RED OAK 5,306.73 0 30 2,531.07 1 080159700 GOOD SAMARITAN SOCIETY-WEST UNION 10,785.21 0 39 331.42 2 080184500 HERITAGE HOUSE 0.00 0 9 0.00 1 080194400 HOLY SPIRIT RETIREMENT HOME 8,374.65 0 31 0.00 1 080228000 LUTHER MANOR RETIREMENT HOME 48.68 0 4 0.00 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 14,986.29 0 101 4,914.00 2 080237100 MADRID HOME FOR THE AGING 10,110.60 0 30 0.00 1 080268600 METHODIST MANOR RETIREMENT COMM 6,414.17 0 31 2,937.60 1 080322100 SAVANNAH HEIGHTS 10,149.40 0 31 0.00 1 080381700 STONEHILL CARE CENTER 46.80 0 2 0.00 2 080402100 TRIPOLI NURSING & REHAB 6,659.75 0 30 2,576.95 1 080420300 WEST POINT CARE CENTER 6,095.24 0 31 2,387.91 1 080466600 NEW LONDON SPECIALTY CARE 23,234.27 0 92 2,584.48 2 080479900 WESTVIEW OF INDIANOLA CARE CENTER 2,630.88 1 14 2,218.72 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,732.40 0 39 0.00 1 080498900 SPENCER POST ACUTE REHABILITATION 18,181.52 0 56 0.00 2 080515000 ACCURA HEALTHCARE OF SIOUX CITY 31,114.06 0 124 2,835.90 4 080532500 MONTEZUMA SPECIALTY CARE 1,609.10 0 7 128.38 2 080604200 IOWA VETERANS HOME 2,684,046.36 33 6,275 508,672.13 181 080613300 SPURGEON MANOR INC 27,462.28 0 91 0.00 1 080727100 WAPELLO SPECIALTY CARE 19,713.48 0 90 4,212.12 1 080734700 VIA OF CARLISLE 6,937.98 0 31 892.00 1 080795800 BELLE PLAINE SPECIALTY CARE 720.06 0 3 0.00 1 080803000 CORRECTIONVILLE SPECIALTY CARE 0.00 0 2 517.82 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080807100 CORYDON SPECIALTY CARE 6,531.30 0 30 1,440.00 1 080817000 LANTERN PARK SPECIALTY CARE 4,889.76 0 44 3,738.34 1 080818800 LYON SPECIALTY CARE 5,963.06 0 31 741.00 1 080819600 MANLY SPECIALTY CARE 7,151.06 0 31 771.30 1 080820400 SOUTHRIDGE SPECIALTY CARE 16,600.50 0 62 0.00 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 21,006.31 0 83 4,466.39 2 080825300 PARKRIDGE SPECIALTY CARE 30,634.28 0 92 2,034.00 1 080828700 RIDGEWOOD SPECIALTY CARE 0.00 0 29 0.00 1 080905300 PRAIRIE RIDGE CARE CENTER 8,256.30 0 30 0.00 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 0.00 0 0 0.00 1 080964000 THE AMBASSADOR SIDNEY INC 24,759.60 0 122 4,309.34 2 TOTAL: 3,333,935.30 38 9,179 589,840.34 257 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 2,343.60 0 310 9,070.60 5 011515400 CEDAR VALLEY RANCH 1,228.86 0 123 3,300.00 2 011623600 ANDREW JACKSON CARE 2,622.20 0 310 8,792.00 5 030019700 HOPE HAVEN ADMIN 622.84 0 62 1,660.00 2 030022000 LEONARD WEBSTER 642.84 0 80 2,302.76 1 030025100 SCENIC ACRES 1,401.70 0 183 5,336.36 4 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 2 153 4,401.00 5 030053000 CEDAR VALLEY RANCH 4,727.08 8 395 10,111.38 13 030056100 PRIDE GROUP 2,325.27 12 267 7,947.51 8 030061600 MEDIAPOLIS CARE FACILITY 3,994.78 0 379 9,960.00 4 030061800 PENN CENTER INC 927.44 0 92 2,460.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 740.84 1 61 1,542.00 2 030067300 PARK PLACE 4,193.37 0 411 10,842.00 2 030070700 AREA RESIDENTIAL CARE 845.68 0 124 3,720.00 4 030084800 COUNTRY CARE CENTER CORP 228.54 0 31 912.88 1 030085500 CEDAR VALLEY RANCH 2,005.10 0 155 3,702.00 5 030091900 PRIDE GROUP 480.96 4 59 1,755.00 5 030093900 ANDREW JACKSON CARE 4,120.72 0 496 14,142.00 8 030123700 MICHAEL GIVANS 867.44 0 92 2,520.00 1 030125900 NISHNA PRODUCTIONS RES COOR 467.42 1 30 674.00 1 030136600 RINGGOLD CO GROUP HOME 753.26 2 91 2,671.00 3 030235000 PRIDE GROUP 438.84 0 62 1,844.00 2 030252000 HOWARD COLE 272.42 0 31 869.00 1 030263200 HORIZONS UNLIMITED 612.84 0 62 1,670.00 2 030284600 STEVEN CAREY 4,410.11 0 214 3,440.54 1 030294900 DAVID GIOVANNONI 62.42 0 31 1,079.00 1 030302100 KEVIN BANWART 0.00 0 0 0.00 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 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 030459500 PRIDE GROUP 964.26 0 93 2,460.00 3 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 218.65 0 31 922.77 1 030475000 THE PRIDE GROUP 155.42 1 30 986.00 1 030476500 HILLCREST 395.42 0 31 746.00 1 030487400 THE PRIDE GROUP 137.42 0 31 1,004.00 1 030492000 COMP SYSTEMS 590.42 5 26 551.00 1 030492900 NORTH IA TRANSITION CENT 1,141.42 0 31 0.00 1 030493500 PRIDE GROUP 993.36 0 95 2,504.54 5 030497500 JAY BAKER 38.42 0 31 1,103.00 1 030524800 HDC 924.26 0 93 2,500.00 3 030526100 JARED SCHAER 927.44 0 92 2,460.00 1 030550500 JULIA LINNANE 301.42 0 31 840.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030552100 VF SHERIDAN SPRINGS 1,221.21 0 124 3,344.47 4 030552700 SHERIDAN SPRINGS 1,311.66 1 154 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 472.84 1 61 1,810.00 2 030558200 SHELLEY FIEDLER 301.42 0 31 840.00 1 030568200 NANCY NAILL 424.42 0 31 717.00 1 030571800 EDWARD PARROTT 602.84 0 62 1,680.00 1 030578800 COUNTRY CARE 428.32 0 62 1,854.52 2 030587200 CEDAR VALLEY RANCH INC 4,977.70 5 180 1,834.00 3 030587400 ARCBEACON HILL RCF 184.42 0 31 957.00 1 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030612900 HORIZONS UNLIMITED OF PAC INC 1,474.23 6 118 3,091.45 4 030613600 ADELINE COMM. LIVING HOME 515.33 0 31 626.09 1 030614900 VERA FRENCH COMM MENTAL 1,522.52 1 185 5,326.00 6 030615300 BUNKER HILL COMMUNITY LIVING HOME 187.42 0 31 954.00 1 030625400 JUSTIN HAY 594.84 0 62 1,688.00 1 030646400 HORIZONS UNLIMITED 1,669.15 0 124 2,896.53 4 030678600 NINTH STREET GROUP HOME 340.84 4 58 1,942.00 2 030679300 HANDICAPPED DEV GRP HM #8 301.42 6 25 840.00 1 030679400 THE PRIDE GROUP 167.42 0 31 974.00 1 030680100 PRIDE IV 107.42 0 31 1,034.00 1 030685400 PRIDE GROUP @ PRIMGHAR 321.42 0 31 820.00 1 030690000 KEYWAY COMMUNITY LIVING HOME 779.84 0 62 1,503.00 2 030690100 IMAGINE THE POSSIBILITIES INC 635.75 0 31 505.67 1 030745400 NISHNA PRODUCTIONS 741.46 2 91 2,682.80 3 032034100 HOPE HAVEN 0.00 0 20 736.40 1 034414300 REDWOOD COURT 456.42 0 31 685.00 1 035515600 COMP SYSTEMS 2,570.16 13 266 7,702.62 9 035713700 RONALD BRUCE 396.44 0 92 2,991.00 1 036348100 PARK PLACE FOR 981.52 0 124 3,584.16 2 036377000 COUNTRY CARE CENTER 1,773.05 0 124 2,792.63 4 036800100 MAINSTREAM LIVING 321.42 0 31 820.00 1 037594900 MOSAIC 694.84 0 62 1,588.00 1 037611100 PARTNERSHIP FOR PROGRESS 321.42 4 27 820.00 1 038186300 KAIN RINEHART 321.42 0 31 820.00 1 038614400 RISE GROUP HOME 1,606.52 13 173 5,242.00 6 038899100 COMP SYSTEMS MARY A 301.42 0 31 840.00 1 039139100 HOPE HAVEN 642.84 0 62 1,640.00 2 039409800 PRIDE GROUP 382.18 0 62 1,843.00 2 040965600 JOAN ROUTH 206.42 0 31 935.00 1 089006400 PRIDE III 1,713.60 0 180 4,914.00 2 089360200 HORIZONS UNLIMITED OF PAC INC 401.67 1 30 739.75 1 TOTAL: 85,020.03 106 8,302 224,265.86 208 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 43,580.20 0 31 333.16 1 TOTAL: 43,580.20 0 31 333.16 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 09/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 09/28/24 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 088036900 PARK VIEW HOMES 55,407.95 0 155 1,336.00 3 088063300 BLUFF VIEW HOMES 27,464.38 3 59 0.00 1 088068200 PROGRESS INDUSTRIES WEST 13,038.13 7 24 893.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 68,152.85 6 148 0.00 2 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 14,991.60 0 31 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 48,798.94 12 93 0.00 1 TOTAL: 324,738.28 31 693 3,311.82 15 ** END OF REPORT **