IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 065526600 ST JOSEPHS MERCY HOSPITAL 0.00 0 9 0.00 1 065530800 VETERANS MEMORIAL HOSPITAL 0.00 0 11 0.00 1 065550600 CLARINDA REGIONAL HEALTH CENTER 0.00 0 14 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 414,918.99 6 288 1,082.82 13 TOTAL: 433,518.99 6 353 1,082.82 17 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 4,185.46 0 44 937.10 1 080006400 FORT DODGE HEALTH & REHABILITATION 6,283.01 0 27 187.00 1 080006500 CLARION WELLNESS & REHAB CENTER 28,376.24 0 136 5,670.00 3 080008100 LAURENS CARE CENTER 102.02 0 9 0.00 1 080008900 BETTENDORF HEALTH CARE CENTER 20,402.85 0 130 5,610.00 2 080009300 THE ALVERNO HEALTH CARE FACILITY 22,886.78 0 91 4,330.41 1 080010900 PREMIER ESTATES OF TOLEDO 8,905.37 0 31 0.00 1 080017500 DENISON CARE CENTER 0.00 0 27 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 29,609.16 0 108 2,712.00 1 080018100 GRUNDY CARE CENTER 7,362.74 0 28 1,518.30 1 080021500 ACCURA HEALTHCARE OF STANTON 15,116.16 0 91 4,818.30 1 080021800 IVY AT DAVENPORT 8,196.91 0 31 1,072.09 1 080023000 ACCURA HEALTHCARE OF MARSHALLTOWN 17,917.74 0 92 5,947.37 1 080024000 WINDMILL MANOR 3,001.05 0 31 4,932.16 1 080028500 MONTROSE HEALTH CENTER 0.00 0 6 0.00 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 23,492.43 0 81 0.00 2 080034600 ARBOR COURT 446.07 0 91 1,959.98 2 080036700 GOOD SAMARITAN SOCIETY-LE MARS 15,701.00 0 62 4,545.72 1 080065700 PINE ACRES REHAB AND CARE CENTER 16,538.70 0 70 0.00 2 080066500 AZRIA HEALTH LONGVIEW 17,385.26 0 131 2,079.01 3 080067300 ASPIRE OF GOWRIE 8,538.64 0 31 0.00 1 080067400 ASPIRE OF ESTHERVILLE 7,546.64 0 31 0.00 1 080068500 URBANDALE HEALTH CARE CENTER 6,857.68 0 0 6,857.68- 1 080068900 ASPIRE OF DONNELLSON 22,342.66 0 92 2,949.06 1 080069700 PRESTIGE CARE CENTER FAIRFIELD 21,828.30 0 90 2,406.00 1 080071100 VIRGINIA GAY NURSING & REHAB 18,482.96 0 61 825.37 2 080071800 HARMONY DAVENPORT 7,247.31 0 30 1,644.09 1 080072000 HARMONY UTICA RIDGE 6,057.03 0 30 224.43 2 080074100 THE BRIDGES AT ANKENY 17,703.79 0 61 3,947.55 2 080082100 CLARKSVILLE NURSING & REHAB CENTER 7,079.80 0 31 1,638.02 1 080087000 COUNTRY VIEW MANOR INC 8,418.18 0 38 0.00 1 080121700 GRACEWELL AN EVENTIDE COMMUNITY 6,613.96 0 31 1,199.28 1 080141500 GOOD SAMARITAN SOCIETY-ALGONA 8,775.69 0 31 381.09 1 080143100 GOOD SAMARITAN SOCIETY-ESTHERVILLE 6,963.46 0 31 1,851.08 1 080152200 GOOD SAMARITAN SOCIETY-OTTUMWA 25,585.28 0 92 1,287.00 1 080157100 GOOD SAMARITAN SOCIETY-VILLISCA 12,756.86 0 91 11,400.00 1 080158900 GOOD SAMARITAN SOCIETY-WAUKON 1,195.88 0 5 359.57 1 080194400 HOLY SPIRIT RETIREMENT HOME 8,374.65 0 31 0.00 1 080237100 MADRID HOME FOR THE AGING 8,936.14 0 60 11,285.06 1 080268600 METHODIST MANOR RETIREMENT COMM 8,969.33 0 31 326.64 1 080373400 ST FRANCIS MANOR 8,138.70 0 30 1,563.00 1 080399900 TIMELY MISSION NURSING HM 5,999.15 0 25 148.85 1 080453400 SIBLEY SPECIALTY CARE 5,588.64 0 33 2,539.26 1 080466600 NEW LONDON SPECIALTY CARE 216.07 0 0 0.00 2 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 1,785.21 0 7 0.00 1 080513500 ACCURA HEALTHCARE OF AMES 707.68 0 4 387.20 1 080514300 ACCURA HEALTHCARE OF CHEROKEE 4,896.00 0 30 2,372.10 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 31,114.06 0 124 2,835.90 4 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080604200 IOWA VETERANS HOME 2,789,351.88 37 6,574 556,750.57 190 080613300 SPURGEON MANOR INC 8,512.10 0 30 527.50 1 080727100 WAPELLO SPECIALTY CARE 32.31 0 8 0.00 1 080732100 FLEUR HEIGHTS CENTER FOR WELLNESS & 22,720.60 0 92 2,676.00 1 080734700 VIA OF CARLISLE 6,937.98 0 31 892.00 1 080758600 WELLINGTON PLACE 0.00 0 27 0.00 1 080794100 BEDFORD SPECIALTY CARE 16,045.67 0 92 6,002.13 1 080795800 BELLE PLAINE SPECIALTY CARE 0.00 0 2 480.04 1 080805500 LAPORTE CITY SPECIALTY CARE 136.39 0 0 0.00 1 080812100 DUBUQUE SPECIALTY CARE 0.00 0 1 0.00 1 080818800 LYON SPECIALTY CARE 5,963.06 0 31 741.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 28,367.25 0 123 4,566.00 2 080822000 NORTHERN MAHASKA SPECIALTY CARE 9,581.80 0 44 4,013.71 3 080824600 SOUTHERN HILLS SPECIALTY CARE 6,472.37 0 31 1,875.00 1 080825300 PARKRIDGE SPECIALTY CARE 75.81 0 40 0.00 2 080833700 PINNACLE SPECIALTY CARE 14,656.18 0 62 2,064.60 1 080913700 WESTBROOK ACRES 21,927.36 0 91 0.00 1 080964000 THE AMBASSADOR SIDNEY INC 7,148.10 0 30 0.00 1 TOTAL: 3,462,557.56 37 9,777 671,620.86 274 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 1,311.14 0 155 4,395.96 5 011515400 CEDAR VALLEY RANCH 632.44 0 92 2,755.00 2 011623600 ANDREW JACKSON CARE 1,593.10 0 180 5,034.50 6 014759500 RINGGOLD CO GROUP HOME 321.42 0 31 820.00 1 030019700 HOPE HAVEN ADMIN 1,484.20 0 86 1,660.00 2 030022000 LEONARD WEBSTER 1,248.86 0 123 3,280.00 1 030025100 SCENIC ACRES 1,095.68 9 115 3,470.00 4 030030700 SUSAN HESPEN 331.69 0 31 809.73 1 030032800 RISE LTD 321.42 7 24 820.00 1 030039200 COMPREHENSIVE SYSTEMS 2,801.20 3 307 8,613.00 5 030053000 CEDAR VALLEY RANCH 4,727.08 8 395 10,111.38 13 030056100 PRIDE GROUP 2,280.54 1 211 5,525.30 8 030061600 MEDIAPOLIS CARE FACILITY 2,344.08 0 244 6,640.00 4 030061800 PENN CENTER INC 321.42 0 31 820.00 1 030067300 PARK PLACE 602.84 0 62 1,680.00 2 030084800 COUNTRY CARE CENTER CORP 228.54 0 31 912.88 1 030085500 CEDAR VALLEY RANCH 98.26 0 93 3,326.00 5 030086900 HILLCREST FAMILY SERVICES 4,295.78 15 414 11,500.00 3 030091900 PRIDE GROUP 1,263.68 16 108 3,302.00 4 030093900 ANDREW JACKSON CARE 2,060.36 0 248 7,071.00 8 030123700 MICHAEL GIVANS 566.02 0 61 1,680.00 1 030125900 NISHNA PRODUCTIONS RES COOR 467.42 2 29 674.00 1 030136600 RINGGOLD CO GROUP HOME 753.26 0 93 2,671.00 3 030149100 PATHWAYS 625.94 0 17 0.00 1 030190300 PENN CENTER INC 4,390.20 0 610 18,070.00 10 030235000 PRIDE GROUP 438.84 0 62 1,844.00 2 030252000 HOWARD COLE 2,032.08 0 244 6,952.00 1 030263200 HORIZONS UNLIMITED 612.84 0 62 1,670.00 2 030284600 STEVEN CAREY 598.63 0 31 542.79 1 030294900 DAVID GIOVANNONI 62.42 0 31 1,079.00 1 030302100 KEVIN BANWART 401.34 0 31 740.08 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 167.16 1 30 974.26 1 030381200 TRAVIS BROWN 301.42 0 31 840.00 1 030382600 HANDICAPPED DEV CENTER 301.42 12 19 840.00 1 030401800 ASHLIE RAGON 642.84 2 60 1,640.00 1 030409400 NEW HAMPTON GROUP HOME 602.84 0 62 1,680.00 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 437.30 0 62 1,845.54 1 030464300 ABBE HEALTH 17,585.55 29 1,847 51,488.77 24 030475000 THE PRIDE GROUP 155.42 2 29 986.00 1 030476500 HILLCREST 5,199.19 4 505 13,502.20 4 030481800 HILLCREST 3,388.34 0 337 9,020.00 2 030487400 THE PRIDE GROUP 137.42 0 31 1,004.00 1 030492000 COMP SYSTEMS 1,180.84 9 53 1,102.00 1 030493500 PRIDE GROUP 963.40 0 117 3,344.54 4 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030497500 JAY BAKER 38.42 0 31 1,103.00 1 030522100 GREGORY CASSI 1,141.42 4 27 0.00 1 030524800 HDC 622.84 0 75 2,138.66 3 030526100 JARED SCHAER 606.02 0 61 1,640.00 1 030550500 JULIA LINNANE 301.42 0 31 840.00 1 030552100 VF SHERIDAN SPRINGS 1,221.21 1 123 3,344.47 4 030552700 SHERIDAN SPRINGS 2,638.39 1 212 5,204.27 6 030557100 VERA FRENCH SHERIDAN SPRING 472.84 0 62 1,810.00 2 030568200 NANCY NAILL 848.84 0 62 1,434.00 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 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030606900 ABBE CENTER BUS OFFICE 2,697.56 3 305 8,643.00 5 030612900 HORIZONS UNLIMITED OF PAC INC 958.49 5 58 1,361.17 4 030614900 VERA FRENCH COMM MENTAL 1,174.41 5 147 4,422.23 5 030646400 HORIZONS UNLIMITED 952.73 0 93 2,471.53 3 030678600 NINTH STREET GROUP HOME 681.68 7 117 3,884.00 2 030679100 ABBE CENTER FOR COMMUNITY MENTAL 1,852.90 0 245 7,168.00 3 030679300 HANDICAPPED DEV GRP HM #8 301.42 0 31 840.00 1 030680100 PRIDE IV 107.42 0 31 1,034.00 1 030680600 ABBE CENTER FOR CMH 1,168.86 0 123 3,360.00 1 030685400 PRIDE GROUP @ PRIMGHAR 321.42 0 31 820.00 1 030690100 IMAGINE THE POSSIBILITIES INC 635.75 0 31 505.67 1 030690900 ABBE CENTER FOR CMH 1,811.70 2 173 4,631.80 2 030745400 NISHNA PRODUCTIONS 741.46 0 93 2,682.80 3 035515600 COMP SYSTEMS 5,140.32 10 548 15,405.24 9 035713700 RONALD BRUCE 144.42- 0 31 997.00- 1 036348100 PARK PLACE FOR 301.42 0 31 840.00 2 036376200 HILLCREST 1,854.88 0 184 4,920.00 1 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 347.42 0 31 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 321.42 0 31 820.00 1 038186300 KAIN RINEHART 321.42 0 31 820.00 1 038614400 RISE GROUP HOME 1,606.52 7 179 5,242.00 6 038700100 KEVINGTON LANE INC 330.42 0 31 811.00 1 038899100 COMP SYSTEMS MARY A 602.84 0 62 1,680.00 1 039460100 PRIDE GROUP 321.42 0 31 820.00 1 040965600 JOAN ROUTH 206.42 0 31 935.00 1 089360200 HORIZONS UNLIMITED OF PAC INC 435.14 0 61 1,810.88 1 089493100 MEDIAPOLIS CARE FACILITY 1,087.42 0 31 54.00 1 089522700 PARK PLACE 243.42 0 31 898.00 1 089558100 CEDAR VALLEY RANCH, INC. 113.42 0 31 1,028.00 1 TOTAL: 111,168.12 165 11,468 317,067.80 244 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 24,613.00 0 14 494.46 1 TOTAL: 24,613.00 0 14 494.46 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 11/30/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 11/23/24 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 088026000 HILLS AND DALES 14,568.10 4 27 0.00 1 088068200 PROGRESS INDUSTRIES WEST 14,037.83 2 29 0.00 1 088127600 BALANCE AUTISM 97,110.20 0 213 0.00 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 14,991.60 0 31 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 116,106.66 32 242 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,537.00 0 31 1,051.60 1 088211800 CHILDSERVE HOMES KEYSTONE 14,544.04 2 29 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,566.32 1 30 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,499.48 4 27 0.00 1 TOTAL: 368,229.52 45 752 1,051.60 12 ** END OF REPORT **