IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 065583700 CENTRAL COMMUNITY HOSPITAL 0.00 0 10 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 302,422.83 0 241 1,051.60 7 TOTAL: 318,622.83 0 278 1,051.60 9 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080002700 NORTHCREST LIVING CENTER 0.00 0 0 0.00 1 080004300 CLAREMONT'S RAMSEY VILLAGE LLC 7,195.61 0 31 2,677.27 1 080006400 FORT DODGE HEALTH & REHABILITATION 5,753.40 0 31 1,675.13 1 080006900 GREATER SOUTHSIDE HEALTH AND REHABI 7,857.40 0 30 1,700.00 1 080008100 LAURENS CARE CENTER 0.00 0 9 0.00 1 080010900 PREMIER ESTATES OF TOLEDO 8,618.10 0 30 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,978.10 0 30 0.00 1 080018300 OSAGE REHAB & HEALTH CARE CENTER 7,020.12- 0 30 1,651.08- 1 080021800 IVY AT DAVENPORT 89,619.49 0 336 10,685.81 2 080029400 UNIVERSITY PARK NURSING & REHAB CEN 12,761.32 0 44 0.00 1 080029600 REGENCY PARK NURSING & REHAB CENTER 0.00 0 0 0.00 1 080034600 ARBOR COURT 684.13 0 72 979.99 2 080065700 PINE ACRES REHAB AND CARE CENTER 0.00 0 0 0.00 1 080066500 AZRIA HEALTH LONGVIEW 15,636.33 0 59 2,079.01 2 080066600 AZRIA HEALTH ROSE VISTA 532.00- 0 0 532.00 1 080066800 SILVER OAK NURSING & REHABILITATION 41,245.25 0 152 9,781.15 2 080071600 HARMONY WEST DES MOINES 25,303.07 0 91 3,511.17 1 080081300 COMMUNITY CARE CENTER 25,031.61 0 122 6,223.57 2 080082100 CLARKSVILLE NURSING & REHAB CENTER 11,909.84 0 54 3,276.04 1 080096100 DAVENPORT LUTHERAN HOME 3,326.85 0 92 20,958.39 1 080142300 GOOD SAMARITAN SOCIETY-DAVENPORT 19,341.13 0 96 6,327.72 3 080152200 GOOD SAMARITAN SOCIETY-OTTUMWA 20,361.90 0 121 14,980.99 2 080154800 GOOD SAMARITAN SOCIETY RED OAK 22.13 0 1 0.00 1 080159700 GOOD SAMARITAN SOCIETY-WEST UNION 64.48 0 14 0.00 1 080184500 HERITAGE HOUSE 8,292.90 0 31 885.58 1 080194400 HOLY SPIRIT RETIREMENT HOME 8,104.50 0 30 0.00 1 080204100 IOOF HOME & COMMUNITY THERAPY CENTE 9,070.11 0 33 1,070.13 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 7,766.70 0 60 885.60 2 080373400 ST FRANCIS MANOR 8,462.09 0 31 1,563.00 1 080381700 STONEHILL CARE CENTER 97.07 0 0 0.00 1 080393200 SUNRISE TERRACE NURSING & REHAB 720.60 0 4 335.00 1 080473200 OAKWOOD CARE CENTER 0.00 0 21 0.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 7,772.41 0 48 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 30,018.90 0 120 2,835.90 4 080547300 SUNNY VIEW CARE CENTER 22,333.23 0 91 847.20 2 080604200 IOWA VETERANS HOME 2,637,837.18 38 6,180 508,052.29 184 080734700 VIA OF CARLISLE 5,836.31 0 30 892.00 1 080804800 KINGSLEY SPECIALTY CARE 3,815.60 0 20 912.80 1 080805500 LAPORTE CITY SPECIALTY CARE 14.52 0 0 0.00 1 080807100 CORYDON SPECIALTY CARE 175.00- 0 0 175.00 1 080815400 HERITAGE SPECIALTY CARE 25,271.54 0 95 107.58 2 080818800 LYON SPECIALTY CARE 5,746.80 0 30 741.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 11,167.10 0 44 613.90 3 080822000 NORTHERN MAHASKA SPECIALTY CARE 5,651.46 0 18 0.00 1 080825300 PARKRIDGE SPECIALTY CARE 29.01 0 50 0.00 3 080826100 NORTHCREST SPECIALTY CARE 15,160.08 0 57 3,517.68 1 080833700 PINNACLE SPECIALTY CARE 16,990.47 0 63 0.00 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 20,807.28 0 26 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080964000 THE AMBASSADOR SIDNEY INC 12,857.63 0 61 2,260.00 1 TOTAL: 3,159,806.51 38 8,528 609,431.82 250 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 835.58 0 119 3,546.00 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 030019700 HOPE HAVEN ADMIN 549.20 0 60 1,660.00 2 030022000 LEONARD WEBSTER 284.60 0 30 820.00 1 030025100 SCENIC ACRES 948.40 0 120 3,470.00 4 030030700 SUSAN HESPEN 294.87 0 30 809.73 1 030032800 RISE LTD 284.60 8 22 820.00 1 030039200 COMPREHENSIVE SYSTEMS 1,046.40 0 120 3,372.00 4 030053000 CEDAR VALLEY RANCH 4,248.42 9 381 10,111.38 13 030056100 PRIDE GROUP 1,495.60 20 182 5,942.04 8 030064600 NORTH IOWA TRANSITIONAL CENTER 0.00 1 20 773.22 3 030067300 PARK PLACE 529.20 0 60 1,680.00 2 030084800 COUNTRY CARE CENTER CORP 191.72 0 30 912.88 1 030085500 CEDAR VALLEY RANCH 904.40 0 120 3,514.00 4 030086900 HILLCREST FAMILY SERVICES 2,139.48 0 214 5,740.00 1 030091900 PRIDE GROUP 1,399.10 0 150 4,096.00 4 030093900 ANDREW JACKSON CARE 1,765.80 0 240 7,071.00 8 030125900 NISHNA PRODUCTIONS RES COOR 430.60 1 29 674.00 1 030136600 RINGGOLD CO GROUP HOME 642.80 0 90 2,671.00 3 030190300 PENN CENTER INC 3,951.36 0 548 16,226.00 10 030235000 PRIDE GROUP 365.20 0 60 1,844.00 2 030252000 HOWARD COLE 235.60 0 30 869.00 1 030263200 HORIZONS UNLIMITED 539.20 0 60 1,670.00 2 030284600 STEVEN CAREY 561.81 0 30 542.79 1 030294900 DAVID GIOVANNONI 25.60 0 30 1,079.00 1 030302100 KEVIN BANWART 104.27 1 29 1,000.33 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 130.34 1 29 974.26 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 030459500 PRIDE GROUP 1,136.50 2 118 3,254.00 3 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 181.83 5 25 922.77 1 030464300 ABBE HEALTH 11,006.77 60 1,155 33,700.70 21 030475000 THE PRIDE GROUP 118.60 0 30 986.00 1 030476500 HILLCREST 1,207.31- 0 122 3,228.00- 1 030487400 THE PRIDE GROUP 100.60 0 30 1,004.00 1 030493500 PRIDE GROUP 1,073.86 0 120 3,344.54 4 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 1,073.93 0 120 3,344.47 4 030552700 SHERIDAN SPRINGS 1,127.56 8 142 4,395.44 5 030557100 VERA FRENCH SHERIDAN SPRING 399.20 0 60 1,810.00 2 030578800 COUNTRY CARE 354.68 0 60 1,854.52 2 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030587200 CEDAR VALLEY RANCH INC 375.20 0 60 1,834.00 2 030597500 SARAH KUNATH 104.70 0 24 756.66 1 030606900 ABBE CENTER BUS OFFICE 2,642.28 15 319 9,655.60 5 030612900 HORIZONS UNLIMITED OF PAC INC 1,482.95 5 115 2,935.45 4 030614900 VERA FRENCH COMM MENTAL 1,100.77 0 150 4,422.23 5 030625400 JUSTIN HAY 260.60 0 30 844.00 1 030646400 HORIZONS UNLIMITED 1,521.87 0 120 2,896.53 4 030679100 ABBE CENTER FOR COMMUNITY MENTAL 606.02 0 61 1,640.00 1 030679300 HANDICAPPED DEV GRP HM #8 264.60 0 30 840.00 1 030679400 THE PRIDE GROUP 133.70 0 30 943.00 1 030680100 PRIDE IV 70.60 0 30 1,034.00 1 030680600 ABBE CENTER FOR CMH 264.60 0 30 840.00 1 030685400 PRIDE GROUP @ PRIMGHAR 284.60 0 30 820.00 1 030690100 IMAGINE THE POSSIBILITIES INC 598.93 0 30 505.67 1 030690900 ABBE CENTER FOR CMH 264.60 0 30 840.00 1 030745400 NISHNA PRODUCTIONS 2,877.02 0 151 2,682.80 3 034414300 REDWOOD COURT 198.68 0 24 685.00 1 035497700 NORTH IOWA TRANS CENTER 0.00 0 3 110.46 1 035515600 COMP SYSTEMS 1,278.38 3 147 4,244.62 5 036348100 PARK PLACE FOR 417.12 0 60 1,792.08 2 036377000 COUNTRY CARE CENTER 1,625.77 0 120 2,792.63 4 036800100 MAINSTREAM LIVING 284.60 0 30 820.00 1 037594900 MOSAIC 310.60 0 30 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 284.60 0 30 820.00 1 038186300 KAIN RINEHART 284.60 0 30 820.00 1 038614400 RISE GROUP HOME 1,410.00 3 177 5,217.60 6 038700100 KEVINGTON LANE INC 293.60 0 30 811.00 1 039139100 HOPE HAVEN 127.36 0 48 1,640.00 2 039409800 PRIDE GROUP 282.70 0 30 794.00 1 040965600 JOAN ROUTH 169.60 0 30 935.00 1 089501100 HILLCREST FAMILY SERVICES 1,207.31 0 122 3,228.00 1 089522700 PARK PLACE 311.42 0 31 830.00 1 TOTAL: 65,057.55 142 7,323 209,641.00 212 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 42,136.46 0 30 360.34 1 TOTAL: 42,136.46 0 30 360.34 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 10/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 10/26/24 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 14,236.80 0 30 0.00 1 088026000 HILLS AND DALES 12,732.60 3 24 0.00 1 088068200 PROGRESS INDUSTRIES WEST 14,476.62 2 28 893.00- 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 24,162.90 0 30 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,118.00 0 30 0.00 1 088175500 TANAGER PLACE 14,508.00 0 30 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,066.40 0 30 1,051.60 1 088211800 CHILDSERVE HOMES KEYSTONE 14,028.88 4 26 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,118.00 0 30 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,051.16 3 27 0.00 1 TOTAL: 149,499.36 12 285 158.60 10 ** END OF REPORT **