IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 18,000.00 0 30 0.00 1 065163800 ON WITH LIFE 4,819.62 0 0 0.00 2 065503500 MANNING REGIONAL HEALTHCARE CENTER 0.00 0 2 0.00 1 065509200 HANCOCK CO MEMORIAL HOSP 0.00 0 0 0.00 1 065993800 CHILDSERVE HABILITATION CENTER 236,203.76 1 186 1,166.49 6 TOTAL: 259,023.38 1 218 1,166.49 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080006300 CAREAGE HILLS REHAB & HEALTHCARE 10,340.68 0 74 2,921.72 2 080008900 BETTENDORF HEALTH CARE CENTER 0.00 0 31 1,581.00 1 080009300 THE ALVERNO HEALTH CARE FACILITY 4,787.65 0 24 2,390.51 1 080017600 CASA DE PAZ HEALTH CARE CENTER 9,277.37 0 31 0.00 2 080017800 CEDAR FALLS HEALTH CARE CENTER 1,153.53 0 1 841.03- 1 080019600 BISHOP DRUMM 3,178.40 0 16 1,020.00 1 080021800 IVY AT DAVENPORT 1,399.17 0 1 1,100.17- 1 080023000 ACCURA HEALTHCARE OF MARSHALLTOWN 8,027.14 0 31 0.00 1 080025300 RED OAK REHAB AND CARE CENTER 59.90 0 67 0.00 1 080025900 PILLAR OF CEDAR VALLEY 5,289.84 0 31 0.00 1 080026600 SOUTHEAST IOWA REGIONAL MEDICAL CEN 36,384.30 0 121 1,189.50 2 080028300 AZRIA HEALTH CLARINDA 9,663.30 0 30 0.00 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 17,663.86 0 76 318.00 3 080066500 AZRIA HEALTH LONGVIEW 9,662.37 0 56 0.00 1 080068400 NEWTON HEALTH CARE CENTER 11,425.95 0 45 0.00 1 080073200 THE VISTAS AT BETTENDORF 0.00 0 10 0.00 1 080074100 THE BRIDGES AT ANKENY 9,433.90 0 61 3,343.94 1 080074600 COLONIAL MANOR OF ELMA 8,473.64 0 31 461.80 1 080075400 SPENCER POST ACUTE REHABILITATION 8,293.03 0 31 1,738.88 1 080079500 HARMONY MARSHALLTOWN 4,857.24 0 22 1,642.00 1 080081300 COMMUNITY CARE CENTER 5,826.86 0 30 1,795.24 1 080123300 FAITH LUTHERAN HOME 1,941.17 0 30 6,915.43 1 080130800 FRIENDSHIP HAVEN 11,753.23 0 50 2,840.27 2 080141500 GOOD SAMARITAN SOCIETY-ALGONA 2,506.49 4 15 1,924.21 1 080148000 GOOD SAMARITAN SOCIETY-INDIANOLA 55,829.34 0 184 10,774.98 2 080152200 GOOD SAMARITAN SOCIETY-OTTUMWA 2,544.41 1 14 1,544.85 1 080194400 HOLY SPIRIT RETIREMENT HOME 306.11- 0 0 306.11 1 080202500 IOWA JEWISH SENIOR LIFE CT 11,833.91 0 61 6,598.46 1 080232200 THE VINTON LUTHERAN HOME 7,348.75 0 31 1,354.50 1 080234800 LUTHERAN LIVING SENIOR CAMPUS 5,988.00 0 0 5,988.00- 1 080314800 PARKVIEW MANOR CARE CENTER 2,409.12 0 8 0.00 1 080322100 SAVANNAH HEIGHTS 16,164.92 0 61 3,806.48 1 080325400 PLEASANT VIEW INC 1,258.15 0 12 1,797.29 1 080348600 ROCKWELL COMMUNITY NURSING HOME 7,230.12 0 31 836.70 1 080355100 SALEM LUTHERAN HOMES 0.00 0 23 0.00 1 080357700 SCENIC MANOR 6,796.31 0 28 1,229.33 1 080378300 STACYVILLE COMMMUNITY NURSING HOME 0.00 0 0 0.00 1 080453400 SIBLEY SPECIALTY CARE 18,388.32 0 78 823.08 1 080473200 OAKWOOD CARE CENTER 8,809.10 0 61 7,580.38 1 080515000 ACCURA HEALTHCARE OF SIOUX CITY 15,766.46 0 70 2,624.90 4 080532500 MONTEZUMA SPECIALTY CARE 180.00 0 14 0.00 1 080548100 SUNNY HILL CARE CENTER 6,101.32 0 37 2,559.64 1 080554900 LINN MANOR CARE CENTER 7,966.20 0 30 0.00 1 080594500 CLEARVIEW HOME 11,709.50 0 66 75.43 3 080604200 IOWA VETERANS HOME 2,488,155.63 65 6,204 560,134.03 187 080789100 FELLOWSHIP VILLAGE 1,012.86 0 9 1,778.76 1 080805500 LAPORTE CITY SPECIALTY CARE 119.07 0 0 0.00 1 080807100 CORYDON SPECIALTY CARE 18,774.43 0 92 5,670.89 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080810500 CRESTON SPECIALTY CARE 0.00 0 10 0.00 1 080814700 ELDORA SPECIALTY CARE 4,055.86 0 22 1,317.20 1 080815400 HERITAGE SPECIALTY CARE 0.00 0 31 0.00 1 080816200 LAMONI SPECIALTY CARE 547.88 0 54 0.00 1 080818800 LYON SPECIALTY CARE 5,940.06 0 31 764.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 5,072.25 0 31 3,228.00 2 080825300 PARKRIDGE SPECIALTY CARE 3,550.90 0 32 0.00 2 080827900 RAVENWOOD SPECIALTY CARE 1,997.95- 0 17 2,659.54- 2 080829500 STRATFORD SPECIALTY CARE 0.00 0 18 0.00 1 080832900 WESTWOOD SPECIALTY CARE 0.00 0 11 0.00 1 080916000 ANAMOSA CARE CENTER 5,516.90 0 31 2,943.00 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 0.00 0 6 2,285.41 1 TOTAL: 2,898,164.73 70 8,289 639,527.18 261 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 629.20 0 62 1,702.00 2 011170800 PARK PLACE 516.05 0 34 762.35 3 011515400 CEDAR VALLEY RANCH 671.80 1 92 2,825.00 3 011623600 ANDREW JACKSON CARE 1,016.40 0 124 3,646.00 4 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 954.80 0 93 2,542.00 3 030030700 SUSAN HESPEN 330.92 0 31 834.68 1 030032800 RISE LTD 324.60 5 26 841.00 1 030039200 COMPREHENSIVE SYSTEMS 729.80 5 98 3,143.00 4 030053000 CEDAR VALLEY RANCH 4,748.80 11 392 10,404.00 13 030056100 PRIDE GROUP 1,122.00 0 208 6,698.80 7 030056600 PRAIRIE VIEW 197.60 0 31 968.00 1 030067300 PARK PLACE 1,395.00 0 69 1,199.40 3 030070700 AREA RESIDENTIAL CARE 693.60 1 120 3,856.00 4 030084800 COUNTRY CARE CENTER CORP 230.72 0 31 934.88 1 030085500 CEDAR VALLEY RANCH 785.40 0 124 3,877.00 4 030086900 HILLCREST FAMILY SERVICES 1,943.42 3 207 5,905.00 3 030091900 PRIDE GROUP 2,476.66 8 299 8,994.00 5 030093900 ANDREW JACKSON CARE 1,445.60 0 166 4,796.00 7 030125900 NISHNA PRODUCTIONS RES COOR 320.70 0 31 844.90 1 030136600 RINGGOLD CO GROUP HOME 802.40 3 121 3,860.00 4 030149100 PATHWAYS 304.60 0 31 861.00 1 030170800 EYERLY BALL CMHS 304.60 0 31 861.00 1 030190300 PENN CENTER INC 2,153.40 0 279 8,337.00 9 030235000 PRIDE GROUP 324.60 19 31 126.60 2 030252000 HOWARD COLE 274.60 0 31 891.00 1 030263200 HORIZONS UNLIMITED 324.60 1 30 841.00 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 030381200 TRAVIS BROWN 304.60 0 31 861.00 1 030382600 HANDICAPPED DEV CENTER 304.60 0 31 861.00 1 030401800 ASHLIE RAGON 324.60 0 31 841.00 1 030406000 STEVEN STRAIGHT 304.60 0 31 861.00 1 030409400 NEW HAMPTON GROUP HOME 304.60 0 31 861.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 295.80- 0 28 757.00- 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 1,295.22 7 137 4,095.00 4 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 275.43 0 31 890.17 1 030464300 ABBE CENTER FOR COMMUNITY MENTAL 6,215.76 54 628 19,404.04 22 030475000 THE PRIDE GROUP 155.60 1 30 1,010.00 1 030476500 HILLCREST 2,406.66 0 341 10,289.36 5 030487400 THE PRIDE GROUP 1,141.42 0 31 0.00 1 030488400 HILLCREST 861.00 0 90 2,523.00 1 030492000 COMP SYSTEMS 509.60 5 26 656.00 1 030493500 PRIDE GROUP 670.20 0 62 1,661.00 2 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030522100 GREGORY CASSI 312.72 0 31 852.88 1 030524800 HDC 629.20 0 62 1,702.00 2 030536000 ABBE 724.60 17 144 5,329.00 3 030552100 VF SHERIDAN SPRINGS 1,232.66 6 118 3,429.74 4 030552700 SHERIDAN SPRINGS 1,354.73 5 150 4,473.27 5 030557100 VERA FRENCH SHERIDAN SPRING 475.20 0 62 1,856.00 2 030558200 SHELLEY FIEDLER 304.60 0 31 861.00 1 030576800 MARY J PARKIN 304.60 2 29 861.00 1 030578800 COUNTRY CARE 430.68 0 62 1,900.52 2 030587200 CEDAR VALLEY RANCH INC 451.20 0 62 1,880.00 2 030587400 ARCBEACON HILL RCF 184.60 0 31 981.00 1 030606900 ABBE CENTER BUS OFFICE 402.34 4 85 2,923.00 3 030612900 HORIZONS UNLIMITED OF PAC INC 1,573.92 3 81 1,584.48 3 030613600 ADELINE COMM. LIVING HOME 304.60 2 29 861.00 1 030614300 IMAGINE THE POSSIBILITIES INC 324.60 0 31 841.00 1 030614900 VERA FRENCH COMM MENTAL 974.17 0 124 3,688.23 4 030615300 BUNKER HILL COMMUNITY LIVING HOME 187.60 0 31 978.00 1 030615600 OPTIMAE LIFE SERVICES 324.60 0 31 841.00 1 030623200 OPTIMAE LIFE SERVICES 953.80 0 93 2,543.00 3 030646400 HORIZONS UNLIMITED 1,576.03 2 153 4,251.97 5 030679100 ABBE CENTER FOR COMMUNITY MENTAL 1,143.40 0 124 3,519.00 4 030679300 HANDICAPPED DEV GRP HM #8 304.60 0 31 861.00 1 030679400 THE PRIDE GROUP 167.42 0 31 974.00 1 030680100 PRIDE IV 390.20 0 62 1,941.00 2 030680600 ABBE CENTER FOR CMH 304.60 0 31 861.00 1 030685400 PRIDE GROUP @ PRIMGHAR 73.20- 0 3 186.00 3 030690000 KEYWAY COMMUNITY LIVING HOME 814.16 2 60 1,517.04 2 030690100 IMAGINE THE POSSIBILITIES INC 442.93 0 56 1,662.67 2 030690900 ABBE CENTER FOR CMH 1,137.40 0 124 3,525.00 4 030693100 ABBE CENTER FOR COMMUNITY MENTAL 324.60 0 31 841.00 1 030745400 NISHNA PRODUCTIONS 738.80 1 92 2,758.00 3 034463000 TERRACE VIEW RESIDENTIAL 203.60 0 31 962.00 1 035515600 COMP SYSTEMS 1,534.43 3 214 6,624.77 7 036348100 PARK PLACE FOR 550.20 0 62 1,781.00 2 036376200 HILLCREST 7,484.94 7 719 19,503.00 5 036377000 COUNTRY CARE CENTER 1,177.46 0 124 3,484.94 4 036800100 MAINSTREAM LIVING 629.20 0 62 1,702.00 2 038186300 KAIN RINEHART 324.60 0 31 841.00 1 038614400 RISE GROUP HOME 1,572.60 1 185 5,421.00 6 038899100 COMP SYSTEMS MARY A 304.60 2 29 861.00 1 039090600 JENNIFER NEUZIL % HILLCRES RCF 8.60 0 59 2,209.80 1 040847600 PRIDE I 94.60 0 31 1,071.00 1 040965600 JOAN ROUTH 206.60 0 31 959.00 1 089002300 IMAGINE THE POSSIBILITIES INC 0.00 0 20 752.00 1 089006400 PRIDE III 324.60 0 31 841.00 1 089400600 COUNTRY CARE CENTER CORP 516.40 0 59 1,702.00 1 089522700 PARK PLACE 118.04 0 59 2,100.36 1 089663900 PRIDE GROUP @ PRIMGHAR 861.00 0 90 2,523.00 1 TOTAL: 75,753.94 144 8,433 246,068.90 247 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 45,428.05 0 31 28.18 1 TOTAL: 45,428.05 0 31 28.18 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 04/30/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 04/26/25 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 15,978.78 0 31 0.00 1 088026000 HILLS AND DALES 31,412.88 4 58 1,806.06- 2 088068200 PROGRESS INDUSTRIES WEST 14,740.74 4 27 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 29,783.22 4 58 0.00 2 088107800 WOODRIDGE HOUSE 14,961.53 0 31 0.00 1 088127600 BALANCE AUTISM 13,426.00 0 28 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 34,505.01 0 31 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,984.78 0 31 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 24,708.44 2 54 0.00 2 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,818.29 0 31 1,166.49 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,961.91 1 30 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 29,717.99 11 51 0.00 2 TOTAL: 252,999.57 26 461 639.57- 16 ** END OF REPORT **