IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 39,700.00 0 31 0.00 1 065502700 PALO ALTO COUNTY HOSPITAL 0.00 0 9 0.00 1 065587800 HANSEN FAMILY HOSPITAL 0.00 0 15 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 265,039.22 10 217 1,162.49 7 TOTAL: 304,739.22 10 272 1,162.49 10 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080003400 RIVER HILLS VILLAGE 0.00 0 24 0.00 1 080006400 FORT DODGE HEALTH & REHABILITATION 0.00 0 30 567.00 1 080006600 HILLCREST HEALTH CARE CENTER 23,071.18 0 96 6,530.40 2 080008100 LAURENS CARE CENTER 171.10 0 16 0.00 1 080009300 THE ALVERNO HEALTH CARE FACILITY 5,733.21 0 61 12,511.28 1 080011800 WESTVIEW ACRES CARE CENTER 3,839.85 0 28 2,893.31 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,599.37 0 31 678.00 1 080017800 CEDAR FALLS HEALTH CARE CENTER 7,903.47 0 31 1,784.03 1 080021800 IVY AT DAVENPORT 8,168.91 0 31 1,100.09 1 080023300 ACCURA HEALTHCARE OF CRESCO 0.00 0 31 0.00 1 080025900 PILLAR OF CEDAR VALLEY 10,409.04 0 61 0.00 1 080028500 MONTROSE HEALTH CENTER 13,784.91 0 109 7,186.95 2 080028600 BIRKWOOD VILLAGE OF FORT MADISON 27,188.42 0 92 2,559.00 1 080028900 NORWALK NURSING AND REHABILITATION 44.02 0 0 44.02- 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 31,156.79 0 123 4,516.90 3 080034600 ARBOR COURT 9.87 0 0 0.00 1 080048200 NEW ALDAYA LIFESCAPES 776.54 5 9 2,201.56 1 080065700 PINE ACRES REHAB AND CARE CENTER 0.00 0 0 0.00 1 080066500 AZRIA HEALTH LONGVIEW 17,109.16 0 139 2,079.01 2 080067900 KEOTA HEALTH CARE CENTER 12,768.83 0 61 3,899.42 1 080068300 KEOSAUQUA HEALTH CARE CENTER 23,355.04 0 92 2,301.00 1 080068500 URBANDALE HEALTH CARE CENTER 3,177.65 0 15 1,426.00 1 080068700 WINSLOW HOUSE CARE CENTER 70,336.92 0 273 9,526.50 3 080069700 PRESTIGE CARE CENTER FAIRFIELD 17,420.77 0 92 7,352.07 1 080070100 STORY MEDICAL SENIOR CARE 8,291.61 0 31 1,390.00 1 080070200 CARING ACRES NURSING AND REHAB CENT 12,857.84 0 92 2,094.00 1 080071300 NORTHBROOK HEALTHCARE AND REHABILIT 0.00 0 19 0.00 1 080071500 HARMONY WATERLOO 152.33 0 6 0.00 1 080071800 HARMONY DAVENPORT 1,847.02 3 46 2,756.30 2 080072000 HARMONY UTICA RIDGE 0.00 0 7 0.00 1 080073600 HALLMAR VILLAGE 514.64 0 41 0.00 1 080121700 GRACEWELL AN EVENTIDE COMMUNITY 0.00 0 0 0.00 1 080143100 GOOD SAMARITAN SOCIETY-ESTHERVILLE 6,255.48 0 22 0.00 1 080148000 GOOD SAMARITAN SOCIETY-INDIANOLA 0.00 0 25 0.00 1 080194400 HOLY SPIRIT RETIREMENT HOME 8,374.65 0 31 0.00 1 080309800 PARKVIEW CARE CENTER 4,621.27 0 54 1,956.00 2 080327000 PLEASANTVIEW HOME 17,393.20 0 58 639.00 2 080333800 GRAND JIVANTE 1,642.27 0 0 1,642.27- 1 080353600 ROTARY SENIOR LIVING 0.00 0 30 0.00 1 080373400 ST FRANCIS MANOR 17,224.42 1 58 1,532.20 1 080381700 STONEHILL CARE CENTER 0.00 0 14 0.00 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 30,566.48 0 122 2,835.90 4 080524200 PERRY LUTHERAN HOME 6,481.82 0 30 1,988.68 1 080531700 STATE CENTER SPECIALTY CARE 16,852.58 0 92 4,803.30 1 080547300 SUNNY VIEW CARE CENTER 254.73 0 1 0.00 1 080604200 IOWA VETERANS HOME 2,498,485.04 71 6,148 524,795.94 195 080707300 LIVING CENTER WEST 17,349.12 0 92 5,178.00 1 080734700 VIA OF CARLISLE 6,901.98 0 31 928.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080789100 FELLOWSHIP VILLAGE 6,422.14 0 23 712.00 1 080792500 ATLANTIC SPECIALTY CARE 12,580.21 0 55 3,018.34 1 080805500 LAPORTE CITY SPECIALTY CARE 10,529.89 0 61 4,240.00 2 080807100 CORYDON SPECIALTY CARE 0.00 0 3 797.13 1 080812100 DUBUQUE SPECIALTY CARE 18,813.88 0 72 1,082.12 3 080816200 LAMONI SPECIALTY CARE 17,039.24 0 91 7,407.00 1 080818800 LYON SPECIALTY CARE 5,963.06 0 31 741.00 1 080819600 MANLY SPECIALTY CARE 2,412.45 0 30 5,254.35 1 080820400 SOUTHRIDGE SPECIALTY CARE 22,665.87 0 120 9,464.13 2 080824600 SOUTHERN HILLS SPECIALTY CARE 0.00 0 3 807.81 1 080825300 PARKRIDGE SPECIALTY CARE 8,204.27 0 30 2,448.43 1 080831100 WEST RIDGE SPECIALTY CARE 52,389.13 0 275 16,891.62 3 080832900 WESTWOOD SPECIALTY CARE 667.80 0 28 828.00 2 080879000 THE VILLAGE 318.73 0 1 0.00 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 155,472.05 0 214 15,787.87 1 TOTAL: 3,254,570.25 80 9,532 687,803.35 277 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 1,778.06 0 183 4,960.00 3 011170800 PARK PLACE 936.71 0 124 3,628.97 4 011515400 CEDAR VALLEY RANCH 953.86 0 123 3,575.00 3 011623600 ANDREW JACKSON CARE 1,291.68 0 154 4,378.60 5 014759500 RINGGOLD CO GROUP HOME 321.42 0 31 820.00 1 030019700 HOPE HAVEN ADMIN 1,156.07 0 145 4,154.00 2 030025100 SCENIC ACRES 2,650.10 3 302 8,580.00 5 030030700 SUSAN HESPEN 327.74 0 31 813.68 1 030032800 RISE LTD 321.42 11 20 820.00 1 030053000 CEDAR VALLEY RANCH 4,693.46 13 390 10,145.00 13 030056100 PRIDE GROUP 2,272.70 11 237 6,801.00 8 030061800 PENN CENTER INC 715.36 9 189 6,575.00 1 030067300 PARK PLACE 640.14 0 62 1,642.70 2 030070700 AREA RESIDENTIAL CARE 1,431.50 6 269 8,694.00 5 030084800 COUNTRY CARE CENTER CORP 228.54 0 31 912.88 1 030085500 CEDAR VALLEY RANCH 1,051.68 0 124 3,514.00 4 030086900 HILLCREST FAMILY SERVICES 21,579.60 85 2,782 83,983.34 16 030091900 PRIDE GROUP 1,240.85 0 124 3,296.00 4 030093900 ANDREW JACKSON CARE 1,738.94 0 217 6,251.00 7 030125900 NISHNA PRODUCTIONS RES COOR 898.02 6 55 1,348.00 1 030136600 RINGGOLD CO GROUP HOME 753.26 1 92 2,671.00 3 030149100 PATHWAYS 301.42 0 31 840.00 1 030190300 PENN CENTER INC 5,021.82 0 651 18,948.00 10 030235000 PRIDE GROUP 438.84 0 62 1,844.00 2 030252000 HOWARD COLE 272.42 0 31 869.00 1 030263200 HORIZONS UNLIMITED 321.42 1 30 820.00 1 030284600 STEVEN CAREY 598.63 0 31 542.79 1 030294900 DAVID GIOVANNONI 62.42 0 31 1,079.00 1 030302100 KEVIN BANWART 0.00 0 17 625.94 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 167.16 1 30 974.26 1 030339500 HILLCREST FAMILY SERVICES 1,076.90 0 245 7,944.00 1 030353600 JUSTIN OLIPHANT 323.42 0 31 818.00 1 030381200 TRAVIS BROWN 301.42 0 31 840.00 1 030382600 HANDICAPPED DEV CENTER 301.42 0 31 840.00 1 030411500 TRACY OLLINGER 383.79 4 87 2,938.00 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 8 85 2,460.00 3 030464300 ABBE CENTER FOR COMMUNITY MENTAL 8,288.48 39 860 24,812.70 23 030475000 THE PRIDE GROUP 155.42 3 28 986.00 1 030476500 HILLCREST 9,555.26 35 2,167 71,522.38 13 030481800 HILLCREST 1,854.88 0 184 4,920.00 2 030487400 THE PRIDE GROUP 137.42 0 31 1,004.00 1 030488400 HILLCREST 3,066.92 0 306 8,200.00 1 030492900 NORTH IA TRANSITION CENT 4,455.22 1 120 0.00 1 030493500 PRIDE GROUP 642.84 0 62 1,640.00 2 030522100 GREGORY CASSI 582.26 2 59 1,663.76 1 030524800 HDC 622.84 0 62 1,660.00 2 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 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 1,644.25 4 182 5,204.27 6 030557100 VERA FRENCH SHERIDAN SPRING 472.84 0 62 1,810.00 2 030558200 SHELLEY FIEDLER 566.02 2 59 1,680.00 1 030576800 MARY J PARKIN 867.44 14 78 2,520.00 1 030578800 COUNTRY CARE 428.32 0 62 1,854.52 2 030587200 CEDAR VALLEY RANCH INC 448.84 3 59 1,834.00 2 030587400 ARCBEACON HILL RCF 332.02 0 61 1,914.00 1 030597500 SARAH KUNATH 140.59 0 31 972.00 1 030606900 ABBE CENTER BUS OFFICE 627.68 2 122 3,938.00 3 030612900 HORIZONS UNLIMITED OF PAC INC 721.50 6 86 2,665.94 4 030613600 ADELINE COMM. LIVING HOME 1,509.17 16 76 1,878.27 1 030614900 VERA FRENCH COMM MENTAL 963.45 3 137 4,191.35 5 030615200 HILLCREST FAMILY SERVICES 68.38 0 59 2,104.00 1 030646400 HORIZONS UNLIMITED 1,254.15 0 124 3,311.53 4 030679100 ABBE CENTER FOR COMMUNITY MENTAL 1,381.46 0 153 4,252.00 3 030679300 HANDICAPPED DEV GRP HM #8 301.42 4 27 840.00 1 030680100 PRIDE IV 107.42 4 27 1,034.00 1 030680600 ABBE CENTER FOR CMH 375.06 4 29 840.00 2 030685400 PRIDE GROUP @ PRIMGHAR 2,613.75 7 162 3,580.00 4 030690000 KEYWAY COMMUNITY LIVING HOME 3,293.50 14 261 6,832.00 2 030690100 IMAGINE THE POSSIBILITIES INC 6,393.44 0 455 10,319.67 3 030690900 ABBE CENTER FOR CMH 1,365.52 11 175 5,483.00 4 030692200 RISE LTD 77.42 0 40 1,395.38 1 030745400 NISHNA PRODUCTIONS 1,372.46 6 177 5,365.60 3 034463000 TERRACE VIEW RESIDENTIAL 203.42 0 31 938.00 1 036348100 PARK PLACE FOR 544.84 0 62 1,738.00 2 036376200 HILLCREST 9,829.70 16 1,056 29,641.34 5 036377000 COUNTRY CARE CENTER 1,161.86 0 124 3,403.82 4 036800100 MAINSTREAM LIVING 850.62 0 91 2,500.00 2 037594900 MOSAIC 347.42 0 31 794.00 1 038258000 BREESE REST HOME 1,363.46 0 153 4,270.00 1 038614400 RISE GROUP HOME 1,220.10 5 150 4,487.00 5 038700100 KEVINGTON LANE INC 330.42 0 31 811.00 1 039090600 JENNIFER NEUZIL % HILLCRES RCF 74.52 1 305 11,192.40 1 040847600 PRIDE I 0.00 0 15 552.30 1 040965600 JOAN ROUTH 206.42 0 31 935.00 1 TOTAL: 132,244.34 362 15,988 469,520.86 254 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 89,657.10 0 62 1,255.36 1 TOTAL: 89,657.10 0 62 1,255.36 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 01/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 01/25/25 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 14,966.49 0 31 0.00 1 088025200 COURAGE HOMES 26,954.68 0 61 0.00 1 088026000 HILLS AND DALES 14,711.95 3 28 0.00 1 088036900 PARK VIEW HOMES 108,985.45 0 305 2,672.00 3 088063300 BLUFF VIEW HOMES 13,242.68 2 28 0.00 1 088068200 PROGRESS INDUSTRIES WEST 19,137.98 7 17 5,358.00- 1 088081500 HACIENDA COMMUNITY LIVING HOME 58,465.52 14 108 0.00 2 088107800 WOODRIDGE HOUSE 14,162.35 0 31 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 14,542.84 5 26 0.00 1 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,426.11 0 31 1,162.49 1 088211800 CHILDSERVE HOMES KEYSTONE 14,521.76 3 28 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,544.04 2 29 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 14,365.80 10 21 0.00 1 TOTAL: 381,584.58 46 806 1,523.51- 18 ** END OF REPORT **