IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 34,800.00 0 58 0.00 1 065501200 SKIFF MEDICAL CENTER SWING BED UNIT 0.00 0 21 0.00 1 065580300 JEFFERSON COUNTY HEALTH CENTER 0.00 0 5 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 283,407.35 9 231 1,128.70 8 TOTAL: 318,207.35 9 315 1,128.70 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080001400 OSKALOOSA CARE CENTER 40,601.62 0 178 11,803.36 3 080002700 NORTHCREST LIVING CENTER 0.00 0 2 20.00 1 080003400 RIVER HILLS VILLAGE 0.00 0 62 0.00 1 080006500 CLARION WELLNESS & REHAB CENTER 37.28 0 15 0.00 1 080006600 HILLCREST HEALTH CARE CENTER 55,161.88 0 209 10,041.94 4 080006900 GREATER SOUTHSIDE HEALTH AND REHABI 7,857.40- 0 30 1,700.00- 1 080008100 LAURENS CARE CENTER 41.26 0 4 0.00 1 080008900 BETTENDORF HEALTH CARE CENTER 706.15 0 12 2,934.17 1 080009300 THE ALVERNO HEALTH CARE FACILITY 9,271.79 0 31 0.00 1 080009500 ADEL ACRES 6,554.82 0 31 1,450.00 1 080015100 ELM CREST RETIREMENT COMMUNITY 0.00 0 10 0.00 1 080017000 ROSE HAVEN NURSING HOME 6,251.25 0 25 881.00 1 080017300 LENOX CARE CENTER 0.00 0 6 0.00 1 080017400 GARDEN VIEW CARE CENTER 3,823.10 0 18 1,162.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,300.10 0 30 678.00 1 080018300 OSAGE REHAB & HEALTH CARE CENTER 13,095.44 0 61 4,536.00 1 080021500 ACCURA HEALTHCARE OF STANTON 13,362.66 0 61 0.00 1 080021800 IVY AT DAVENPORT 12,083.91 0 44 1,072.09 1 080023300 ACCURA HEALTHCARE OF CRESCO 0.00 0 10 0.00 1 080024000 WINDMILL MANOR 4,900.60 0 31 3,032.61 1 080025700 ACCURA HEALTHCARE OF LE MARS 7,076.88 0 31 1,432.00 1 080029300 ALTOONA NURSING & REHABILITATION 13,256.33 0 75 3,593.70 2 080029400 UNIVERSITY PARK NURSING & REHAB CEN 12,129.32 0 44 632.00 2 080030100 PERRY LUTHERAN HOMES EDEN ACRES CAM 5,739.16 0 27 1,985.00 1 080034600 ARBOR COURT 675.72 0 13 289.00 8 080036700 GOOD SAMARITAN SOCIETY-LE MARS 6,870.82 0 28 2,272.86 1 080065700 PINE ACRES REHAB AND CARE CENTER 0.00 0 0 0.00 1 080066500 AZRIA HEALTH LONGVIEW 16,323.74 0 89 2,079.01 2 080069700 PRESTIGE CARE CENTER FAIRFIELD 21,583.84 0 92 3,189.00 1 080070800 ENNOBLE NURSING AND REHAB 33,554.15 0 126 3,813.01 2 080071300 NORTHBROOK HEALTHCARE AND REHABILIT 48.43 0 6 0.00 1 080071600 HARMONY WEST DES MOINES 0.00 0 2 0.00 1 080072000 HARMONY UTICA RIDGE 0.00 0 17 0.00 1 080073100 EAGLE POINT NURSING AND REHABILITAT 36,169.66 0 138 3,665.42 2 080073600 HALLMAR VILLAGE 2,290.99 0 152 0.00 1 080079700 CROWN POINTE ESTATES CARE CENTER 24,799.78 0 91 1,769.49 1 080087000 COUNTRY VIEW MANOR INC 4,876.65 2 29 1,433.75 1 080096100 DAVENPORT LUTHERAN HOME 12,342.17 0 61 3,760.00 1 080123300 FAITH LUTHERAN HOME 2,950.59 0 20 2,352.01 1 080131600 FRIENDSHIP HOME 11,763.34 0 57 546.50 1 080142300 GOOD SAMARITAN SOCIETY-DAVENPORT 422.67 0 26 0.00 1 080147200 GOOD SAMARITAN SOCIETY-HOLSTEIN 0.00 0 3 917.64 1 080152200 GOOD SAMARITAN SOCIETY-OTTUMWA 0.00 0 14 4,089.26- 1 080180300 COMMUNITY MEMORIAL HEALTH CENTER 21,653.96 0 91 7,183.62 1 080194400 HOLY SPIRIT RETIREMENT HOME 17,751.93 0 120 14,666.07 2 080228000 LUTHER MANOR AT HILLCREST 6,499.34 0 38 2,274.90 2 080232200 THE VINTON LUTHERAN HOME 33,926.40 0 154 9,120.00 2 080234800 LUTHERAN LIVING SENIOR CAMPUS 0.00 0 9 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080309800 PARKVIEW CARE CENTER 17,104.64 0 92 2,415.00 1 080333800 GRAND JIVANTE 0.00 0 7 1,642.27 1 080353600 ROTARY SENIOR LIVING 0.00 0 7 0.00 1 080381700 STONEHILL CARE CENTER 132.06 0 0 0.00 1 080397300 THOMAS REST HAVEN 153.13 0 28 0.00 1 080406200 HEGG MEMORIAL HEALTH CENTER 6,851.26 0 30 2,077.34 1 080479900 WESTVIEW OF INDIANOLA CARE CENTER 9,075.43 0 31 1,662.97 1 080500200 ALGONA MANOR CARE CENTER 0.00 0 13 0.00 1 080513500 ACCURA HEALTHCARE OF AMES 387.20 0 0 387.20- 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 30,018.90 0 120 2,835.90 4 080525900 ACCURA HEALTHCARE OF OGDEN 4,401.00 0 31 2,709.47 1 080548100 SUNNY HILL CARE CENTER 3,511.20 0 15 0.00 1 080582000 CEDAR MANOR NURSING HOME 38,033.98 0 151 2,406.84 2 080604200 IOWA VETERANS HOME 2,283,508.72 50 6,109 503,613.89 201 080707300 LIVING CENTER WEST 5,575.80 0 30 1,770.00 1 080734700 VIA OF CARLISLE 6,685.40 0 30 892.00 1 080758600 WELLINGTON PLACE 0.00 0 24 0.00 1 080789100 FELLOWSHIP VILLAGE 7,650.40 0 30 1,655.00 1 080794100 BEDFORD SPECIALTY CARE 155.07 0 41 0.00 1 080795800 BELLE PLAINE SPECIALTY CARE 7,440.62 0 31 0.00 1 080800600 AVOCA SPECIALTY CARE 741.15 0 4 316.49 1 080803000 CORRECTIONVILLE SPECIALTY CARE 0.00 0 1 0.00 1 080805500 LAPORTE CITY SPECIALTY CARE 96.03 0 0 0.00 1 080813900 DUNLAP SPECIALTY CARE 0.00 0 27 958.00 1 080818800 LYON SPECIALTY CARE 5,746.80 0 30 741.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 535.50 0 28 0.00 2 080825300 PARKRIDGE SPECIALTY CARE 0.00 0 30 0.00 1 080826100 NORTHCREST SPECIALTY CARE 0.00 0 5 1,594.50 1 080831100 WEST RIDGE SPECIALTY CARE 7,284.85 0 45 4,052.00 1 080906100 COLONIAL MANORS OF COLUMBUS COMMUNI 2,555.70 0 10 0.00 1 TOTAL: 2,896,685.17 52 9,309 629,752.36 303 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 011170800 PARK PLACE 296.34 0 59 1,876.04 5 011515400 CEDAR VALLEY RANCH 274.20 0 60 1,935.00 2 011623600 ANDREW JACKSON CARE 1,409.00 0 180 5,218.60 6 014759500 RINGGOLD CO GROUP HOME 1,278.74 0 57 820.00 1 030019700 HOPE HAVEN ADMIN 676.56 0 108 3,300.00 2 030030700 SUSAN HESPEN 290.92 0 30 813.68 1 030032800 RISE LTD 284.60 7 23 820.00 1 030053000 CEDAR VALLEY RANCH 4,248.42 3 387 10,111.38 13 030056100 PRIDE GROUP 1,495.60 0 174 4,911.08 6 030067300 PARK PLACE 566.50 0 60 1,642.70 2 030070700 AREA RESIDENTIAL CARE 2,298.22 0 353 10,699.24 4 030084800 COUNTRY CARE CENTER CORP 191.72 0 30 912.88 1 030085500 CEDAR VALLEY RANCH 1,171.02 0 211 6,598.00 5 030086900 HILLCREST FAMILY SERVICES 227.78 0 29 840.00 1 030091900 PRIDE GROUP 1,397.20 19 150 4,769.58 4 030093900 ANDREW JACKSON CARE 1,297.10 0 205 6,251.00 7 030136600 RINGGOLD CO GROUP HOME 642.80 0 90 2,671.00 3 030149100 PATHWAYS 264.60 0 30 840.00 1 030190300 PENN CENTER INC 2,333.42 0 331 9,854.00 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 284.60 0 30 820.00 1 030284600 STEVEN CAREY 561.81 0 30 542.79 1 030294900 DAVID GIOVANNONI 25.60 0 30 1,079.00 1 030302100 KEVIN BANWART 193.65 3 27 910.95 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 130.34 1 29 974.26 1 030381200 TRAVIS BROWN 264.60 0 30 840.00 1 030382600 HANDICAPPED DEV CENTER 264.60 3 27 840.00 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 4 116 3,254.00 3 030464300 ABBE HEALTH 7,010.20 37 838 25,207.30 25 030475000 THE PRIDE GROUP 118.60 2 28 986.00 1 030476500 HILLCREST 1,149.44 0 92 2,238.00 1 030487400 THE PRIDE GROUP 100.60 0 30 1,004.00 1 030493500 PRIDE GROUP 789.26 0 90 2,524.54 3 030524800 HDC 549.20 0 60 1,660.00 2 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 1,423.33 0 180 5,204.27 6 030557100 VERA FRENCH SHERIDAN SPRING 399.20 0 60 1,810.00 2 030558200 SHELLEY FIEDLER 867.44 0 92 2,520.00 1 030576800 MARY J PARKIN 566.02 0 61 1,680.00 1 030578800 COUNTRY CARE 354.68 0 60 1,854.52 2 030587200 CEDAR VALLEY RANCH INC 375.20 0 60 1,834.00 2 030587400 ARCBEACON HILL RCF 516.44 0 92 2,871.00 1 030597500 SARAH KUNATH 104.70 0 30 972.00 1 030606900 ABBE CENTER BUS OFFICE 529.20 0 90 2,784.60 3 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030612900 HORIZONS UNLIMITED OF PAC INC 1,467.04 8 112 2,951.36 4 030613600 ADELINE COMM. LIVING HOME 993.84 0 61 1,252.18 1 030614900 VERA FRENCH COMM MENTAL 1,100.77 1 149 4,422.23 5 030646400 HORIZONS UNLIMITED 1,106.87 0 120 3,311.53 4 030679100 ABBE CENTER FOR COMMUNITY MENTAL 417.20 0 60 1,792.00 2 030679300 HANDICAPPED DEV GRP HM #8 264.60 0 30 840.00 1 030679400 THE PRIDE GROUP 205.48 3 27 871.22 1 030680100 PRIDE IV 70.60 1 29 1,034.00 1 030680600 ABBE CENTER FOR CMH 264.60 10 20 840.00 1 030685400 PRIDE GROUP @ PRIMGHAR 851.90 0 90 2,434.00 3 030690100 IMAGINE THE POSSIBILITIES INC 1,029.61 0 42 505.67 1 030690900 ABBE CENTER FOR CMH 646.16 1 87 2,594.00 3 030692200 RISE LTD 406.40 21 131 4,417.02 2 035598200 ALC 0.00 13 138 5,081.16 1 036348100 PARK PLACE FOR 471.20 0 60 1,738.00 2 036377000 COUNTRY CARE CENTER 1,625.77 0 120 2,792.63 4 036800100 MAINSTREAM LIVING 1,439.82 0 151 4,120.00 3 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 10 20 820.00 1 038614400 RISE GROUP HOME 1,410.00 9 171 5,217.60 6 038700100 KEVINGTON LANE INC 293.60 0 30 811.00 1 039409800 PRIDE GROUP 282.70 0 30 794.00 1 040965600 JOAN ROUTH 169.60 0 30 935.00 1 089522700 PARK PLACE 793.23 0 91 2,557.39 2 TOTAL: 56,801.27 156 6,908 201,836.87 200 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 43,724.28 0 30 265.62 1 TOTAL: 43,724.28 0 30 265.62 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 12/31/24 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 12/28/24 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 14,483.70 0 30 0.00 1 088026000 HILLS AND DALES 14,052.16 6 24 0.00 1 088068200 PROGRESS INDUSTRIES WEST 4,542.10 0 10 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 58,694.22 4 118 0.00 2 088107800 WOODRIDGE HOUSE 66,544.78 0 153 0.00 1 088127600 BALANCE AUTISM 57,879.62 0 122 0.00 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 14,416.54 1 29 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 196,763.31 42 415 0.00 2 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 12,989.30 0 30 1,128.70 1 088211800 CHILDSERVE HOMES KEYSTONE 14,073.44 2 28 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,118.00 0 30 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 13,939.76 8 22 0.00 1 TOTAL: 520,777.83 63 1,071 1,128.70 16 ** END OF REPORT **