IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 19,600.00 0 28 0.00 1 065163800 ON WITH LIFE 42,583.46 0 31 0.00 1 065522500 GRAPE COMMUNITY HOSPITAL 0.00 0 13 0.00 1 065587800 HANSEN FAMILY HOSPITAL 0.00 0 17 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 301,848.49 5 217 1,166.49 10 TOTAL: 364,031.95 5 306 1,166.49 14 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080002700 NORTHCREST LIVING CENTER 7,404.70 0 30 512.00 1 080006500 CLARION WELLNESS & REHAB CENTER 0.17 0 3 0.00 1 080006900 GREATER SOUTHSIDE HEALTH AND REHABI 8,175.98 0 31 1,700.00 1 080008100 LAURENS CARE CENTER 76.95 0 15 0.00 1 080015100 ELM CREST RETIREMENT COMMUNITY 0.00 0 10 0.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 45,092.31 0 153 696.00 3 080017800 CEDAR FALLS HEALTH CARE CENTER 5,408.97 0 20 841.03 1 080021500 ACCURA HEALTHCARE OF STANTON 6,424.39- 0 31 983.99- 1 080021800 IVY AT DAVENPORT 6,769.82 0 30 2,200.18 1 080025900 PILLAR OF CEDAR VALLEY 15,698.88 0 92 0.00 1 080027000 WESTWING PLACE 6,662.85 0 31 1,945.54 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 17,332.86 0 62 649.00 2 080036700 GOOD SAMARITAN SOCIETY-LE MARS 12,838.06 0 61 7,082.10 1 080056500 CHAUTAUQUA GUEST HOME #2 6,176.50 0 30 1,544.00 1 080065600 COLONIAL MANOR OF AMANA 4,269.50 4 20 627.70 1 080065700 PINE ACRES REHAB AND CARE CENTER 0.00 0 0 0.00 1 080066500 AZRIA HEALTH LONGVIEW 483.53 0 52 0.00 2 080066800 SILVER OAK NURSING & REHABILITATION 5,035.50 0 15 0.00 1 080067400 ASPIRE OF ESTHERVILLE 883.40 0 4 0.00 1 080067500 ASPIRE OF MUSCATINE 465.86 0 2 0.00 1 080067900 KEOTA HEALTH CARE CENTER 8,271.42 0 16 3,899.42- 1 080068500 URBANDALE HEALTH CARE CENTER 1,029.28 0 8 1,426.00 1 080069700 PRESTIGE CARE CENTER FAIRFIELD 1,024.00 0 0 1,024.00- 1 080071300 NORTHBROOK HEALTHCARE AND REHABILIT 0.00 0 2 0.00 1 080071500 HARMONY WATERLOO 20,633.62 1 86 4,665.00 2 080072000 HARMONY UTICA RIDGE 13,609.83 0 39 0.00 1 080073600 HALLMAR VILLAGE 67.78 0 8 0.00 1 080081300 COMMUNITY CARE CENTER 14,183.79 0 61 1,314.48 1 080119100 WESTHAVEN COMMUNITY 6,866.69 0 31 2,018.22 1 080123300 FAITH LUTHERAN HOME 11,306.10 0 45 1,978.80 2 080136500 GLEN HAVEN VILLAGE 17,492.87 0 61 2,534.04 1 080160500 GOOD SHEPHERD HEALTH CENTER 19,255.05 0 85 0.00 2 080194400 HOLY SPIRIT RETIREMENT HOME 8,335.12 0 31 39.53 1 080204100 IOOF HOME & COMMUNITY THERAPY CENTE 15,296.33 0 49 0.00 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 6,827.20 0 30 1,825.10 1 080267800 METH-WICK HEALTH CENTER 14,400.64 0 92 13,725.60 1 080322100 SAVANNAH HEIGHTS 25,793.47 0 91 3,999.93 1 080353600 ROTARY SENIOR LIVING 0.00 0 24 0.00 2 080374200 ST ANTHONY REGIONAL HOSPITAL 473.80- 0 0 473.80 1 080378300 STACYVILLE COMMMUNITY NURSING HOME 0.00 0 22 0.00 1 080395700 TABOR MANOR CARE CENTER 27,975.82 0 133 5,304.77 4 080420300 WEST POINT CARE CENTER 820.95 0 3 0.00 1 080478100 REHABILITATION CENTER OF HAMPTON 0.00 0 0 0.00 1 080486400 NORTHGATE CARE CENTER 7,161.48 0 31 1,242.00 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 6,678.50 0 31 1,227.43 1 080514300 ACCURA HEALTHCARE OF CHEROKEE 17,143.33 0 92 5,145.51 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 30,852.06 0 124 3,097.90 4 080531700 STATE CENTER SPECIALTY CARE 6,856.39 0 61 7,502.40 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080548100 SUNNY HILL CARE CENTER 12,252.88 0 64 2,728.24 1 080554900 LINN MANOR CARE CENTER 6,844.29 0 30 1,865.31 1 080582000 CEDAR MANOR NURSING HOME 2,410.38 0 9 0.00 1 080604200 IOWA VETERANS HOME 2,547,761.67 76 6,234 521,068.56 194 080812100 DUBUQUE SPECIALTY CARE 184.44 0 42 0.00 2 080814700 ELDORA SPECIALTY CARE 4,949.67 0 30 2,377.23 1 080816200 LAMONI SPECIALTY CARE 7,109.20 0 30 950.00 1 080818800 LYON SPECIALTY CARE 5,940.06 0 31 764.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 8,300.25 0 31 0.00 1 080822000 NORTHERN MAHASKA SPECIALTY CARE 7,356.89 0 37 4,260.00 1 080824600 SOUTHERN HILLS SPECIALTY CARE 0.00 0 92 5,933.94 1 080825300 PARKRIDGE SPECIALTY CARE 108.36 0 35 0.00 2 080827900 RAVENWOOD SPECIALTY CARE 22,751.24 0 92 2,454.00 1 080828700 RIDGEWOOD SPECIALTY CARE 17,228.80 0 92 3,807.00 1 080832900 WESTWOOD SPECIALTY CARE 20,999.38 0 167 18,788.90 4 080866700 HARMONY MARSHALLTOWN 7,663.18 0 29 904.00 1 080879000 THE VILLAGE 8,270.44 0 31 1,610.19 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 10,519.07 4 16 2,285.41 1 080964000 THE AMBASSADOR SIDNEY INC 7,386.37 0 31 0.00 1 080965700 HAPPY SIESTA NURSING HOME 23,384.35 0 85 0.00 1 080980600 HAWKEYE CARE CENTER-DUBUQUE 9,039.84 0 46 4,657.12 1 TOTAL: 3,148,220.13 85 9,140 643,864.55 281 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 841.00 0 90 2,543.00 3 011170800 PARK PLACE 884.51 0 124 3,777.89 4 011515400 CEDAR VALLEY RANCH 671.80 0 93 2,825.00 3 011623600 ANDREW JACKSON CARE 1,670.60 0 186 5,323.00 6 014759500 RINGGOLD CO GROUP HOME 324.60 0 31 841.00 1 030019700 HOPE HAVEN ADMIN 304.60 0 31 861.00 1 030025100 SCENIC ACRES 1,451.00 11 144 4,377.00 5 030030700 SUSAN HESPEN 330.92 0 31 834.68 1 030032800 RISE LTD 324.60 6 25 841.00 1 030039200 COMPREHENSIVE SYSTEMS 4,123.10 4 456 12,935.00 5 030053000 CEDAR VALLEY RANCH 4,748.80 4 399 10,404.00 13 030056100 PRIDE GROUP 2,268.62 3 245 7,032.00 7 030067300 PARK PLACE 609.20 0 62 1,722.00 2 030084800 COUNTRY CARE CENTER CORP 230.72 0 31 934.88 1 030085500 CEDAR VALLEY RANCH 1,034.40 0 124 3,628.00 4 030086900 HILLCREST FAMILY SERVICES 5,514.30 7 624 17,719.12 8 030091900 PRIDE GROUP 2,290.12 0 217 5,772.36 4 030093900 ANDREW JACKSON CARE 1,771.20 0 217 6,388.00 7 030125900 NISHNA PRODUCTIONS RES COOR 491.60 0 31 674.00 1 030136600 RINGGOLD CO GROUP HOME 758.80 0 93 2,738.00 3 030149100 PATHWAYS 304.60 0 31 861.00 1 030170800 EYERLY BALL CMHS 304.60 0 31 861.00 1 030190300 PENN CENTER INC 2,415.00 0 310 9,241.00 10 030235000 PRIDE GROUP 440.20 9 53 1,891.00 2 030252000 HOWARD COLE 274.60 0 31 891.00 1 030263200 HORIZONS UNLIMITED 324.60 0 31 841.00 1 030284600 STEVEN CAREY 251.81 0 31 913.79 1 030294900 DAVID GIOVANNONI 59.60 0 31 1,106.00 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 167.34 1 30 998.26 1 030339500 HILLCREST FAMILY SERVICES 148.42 0 31 993.00 1 030353600 JUSTIN OLIPHANT 326.60 0 31 839.00 1 030381200 TRAVIS BROWN 304.60 0 31 861.00 1 030382600 HANDICAPPED DEV CENTER 304.60 0 31 861.00 1 030401800 ASHLIE RAGON 930.62 0 92 2,481.00 1 030406000 STEVEN STRAIGHT 304.60 0 31 861.00 1 030409400 NEW HAMPTON GROUP HOME 870.62 1 91 2,541.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 361.60 0 31 804.00 1 030425100 THOMAS FAULKNER 43.60 0 31 1,122.00 1 030456600 JACK SCOTT 169.60 0 31 996.00 1 030459500 PRIDE GROUP 1,316.22 1 123 3,322.00 3 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 703.51 1 91 2,708.11 1 030464300 ABBE CENTER FOR COMMUNITY MENTAL 7,895.56 43 781 23,024.44 24 030475000 THE PRIDE GROUP 155.60 1 30 1,010.00 1 030476500 HILLCREST 375.44 14 97 3,711.58 5 030487400 THE PRIDE GROUP 1,165.60 0 31 0.00 1 030492000 COMP SYSTEMS 974.20 11 50 1,296.00 1 030493500 PRIDE GROUP 670.20 0 62 1,661.00 2 030522100 GREGORY CASSI 312.72 0 31 852.88 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030524800 HDC 629.20 0 62 1,702.00 2 030550500 JULIA LINNANE 304.60 0 31 861.00 1 030552100 VF SHERIDAN SPRINGS 1,233.94 0 124 3,428.46 4 030552700 SHERIDAN SPRINGS 1,673.33 8 178 5,320.27 6 030557100 VERA FRENCH SHERIDAN SPRING 475.20 0 62 1,856.00 2 030568200 NANCY NAILL 1,195.36 0 92 2,216.26 1 030578800 COUNTRY CARE 430.68 0 62 1,900.52 2 030587200 CEDAR VALLEY RANCH INC 451.20 1 61 1,880.00 2 030587800 HILLCREST 515.82 0 51 1,362.00 1 030597500 SARAH KUNATH 137.42 0 31 1,004.00 1 030606900 ABBE CENTER BUS OFFICE 936.39 10 114 3,673.00 4 030612900 HORIZONS UNLIMITED OF PAC INC 746.72 1 61 1,584.48 2 030614900 VERA FRENCH COMM MENTAL 974.17 1 123 3,688.23 4 030615200 HILLCREST FAMILY SERVICES 89.42 0 31 1,052.00 1 030623200 OPTIMAE LIFE SERVICES 2,178.76 0 217 5,907.90 4 030645300 OPTIMAE CALHOUN 304.60 0 31 861.00 1 030646400 HORIZONS UNLIMITED 1,266.87 0 124 3,395.53 4 030678600 NINTH STREET GROUP HOME 964.64 23 161 5,858.60 2 030679100 ABBE CENTER FOR COMMUNITY MENTAL 2,944.56 0 262 6,799.00 5 030679200 THUNDERBIRD 530.60 0 31 635.00 1 030679300 HANDICAPPED DEV GRP HM #8 304.60 0 31 861.00 1 030680100 PRIDE IV 106.60 0 31 1,059.00 1 030680600 ABBE CENTER FOR CMH 304.60 12 19 861.00 1 030685400 PRIDE GROUP @ PRIMGHAR 1,172.22 0 124 3,466.00 4 030690100 IMAGINE THE POSSIBILITIES INC 215.15- 0 38 1,662.67 2 030690900 ABBE CENTER FOR CMH 2,553.86 5 272 7,742.00 4 030745400 NISHNA PRODUCTIONS 738.80 0 93 2,758.00 3 034463000 TERRACE VIEW RESIDENTIAL 203.60 0 31 962.00 1 035515600 COMP SYSTEMS 6,748.14 19 747 21,673.60 9 036348100 PARK PLACE FOR 550.20 0 62 1,781.00 2 036376200 HILLCREST 442.84 1 61 1,840.00 1 036377000 COUNTRY CARE CENTER 1,177.46 0 124 3,484.94 4 036800100 MAINSTREAM LIVING 950.62 0 104 2,935.60 3 037594900 MOSAIC 371.60 0 31 794.00 1 037611100 PARTNERSHIP FOR PROGRESS 324.60 5 26 841.00 1 038186300 KAIN RINEHART 324.60 0 31 841.00 1 038614400 RISE GROUP HOME 1,248.00 3 152 4,580.00 5 038700100 KEVINGTON LANE INC 354.60 0 31 811.00 1 038899100 COMP SYSTEMS MARY A 569.20 0 61 1,701.00 1 039409800 PRIDE GROUP 321.42 0 31 820.00 1 040847600 PRIDE I 94.60 0 31 1,071.00 1 040965600 JOAN ROUTH 206.60 0 31 959.00 1 089006900 IMAGINE THE POSSIBILITIES INC 63.68 0 24 820.00 1 TOTAL: 89,421.52 206 9,655 279,030.05 248 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 45,324.73 0 31 131.50 1 TOTAL: 45,324.73 0 31 131.50 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 02/28/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 02/22/25 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 2,404.62 0 0 0.00 1 088026000 HILLS AND DALES 14,803.41 2 29 0.00 1 088036900 PARK VIEW HOMES 24,012.00 0 0 0.00 3 088063300 BLUFF VIEW HOMES 1,662.63 0 0 0.00 1 088068200 PROGRESS INDUSTRIES WEST 27,026.12 32 26 0.00 1 088107800 WOODRIDGE HOUSE 14,162.35 0 31 0.00 1 088127600 BALANCE AUTISM 14,864.50 0 31 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 12,816.53 0 31 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 17,336.30 0 31 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 27,129.92 13 49 0.00 2 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 16,169.81 0 31 1,166.49 1 088211800 CHILDSERVE HOMES KEYSTONE 17,280.53 2 29 0.00 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 17,334.53 0 31 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 17,179.61 6 25 0.00 1 TOTAL: 239,149.35 55 375 1,166.49 18 ** END OF REPORT **