IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 1 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 6,000.00 0 10 0.00 1 065517500 MERCYONE NEW HAMPTON MEDICAL CENTER 0.00 0 3 0.00 1 065589400 CASS COUNTY MEM HOSP 0.00 0 106 0.00 2 065993800 CHILDSERVE HABILITATION CENTER 264,089.75 5 210 1,132.70 7 TOTAL: 270,089.75 5 329 1,132.70 11 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 2 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080004200 OAKLAND MANOR 2,343.64 0 15 2,458.76 1 080006300 CAREAGE HILLS REHAB & HEALTHCARE 6,304.00 0 54 1,064.00 2 080006600 HILLCREST HEALTH CARE CENTER 0.00 0 52 2,796.00 1 080006700 REGENCY CARE CENTER 26,178.20 0 90 1,522.00 1 080006800 PARKVIEW MANOR 0.00 0 61 2,510.00 1 080008900 BETTENDORF HEALTH CARE CENTER 14,598.68 0 61 3,906.28 1 080009900 ACCURA HEALTHCARE OF KNOXVILLE 19,752.10 0 82 3,048.00 1 080011800 WESTVIEW ACRES CARE CENTER 20.00- 0 0 20.00 1 080017600 CASA DE PAZ HEALTH CARE CENTER 8,978.10 0 30 0.00 1 080017800 CEDAR FALLS HEALTH CARE CENTER 16,049.00 0 56 1,451.00 1 080017900 IOWA CITY REHAB & HEALTH CARE CENTE 835.96 0 59 0.00 2 080021800 IVY AT DAVENPORT 3,683.99 0 16 1,100.01 1 080023000 ACCURA HEALTHCARE OF MARSHALLTOWN 7,768.20 0 30 0.00 1 080023100 ACCURA HEALTHCARE OF SPIRIT LAKE 14,842.12 0 61 2,342.80 1 080025100 EMBASSY REHAB AND CARE CENTER 7,441.61 0 28 1,294.11 1 080026600 SOUTHEAST IOWA REGIONAL MEDICAL CEN 36,421.20 0 120 0.00 1 080027900 AZRIA HEALTH PRAIRIE RIDGE 7,679.33 0 34 3,586.91 2 080028300 AZRIA HEALTH CLARINDA 16,468.44 0 61 3,180.27 1 080029400 UNIVERSITY PARK NURSING & REHAB CEN 21,144.22 0 105 1,723.00 4 080034600 ARBOR COURT 13,035.50 0 50 0.00 1 080055700 CHAUTAUQUA GUEST HOMES #3 39,767.16 0 173 3,379.04 3 080065700 PINE ACRES REHAB AND CARE CENTER 18,237.41 0 98 8,793.00 2 080066500 AZRIA HEALTH LONGVIEW 14,990.50 0 75 2,597.00 2 080067900 KEOTA HEALTH CARE CENTER 29,259.75 0 119 3,257.00 2 080071300 NORTHBROOK HEALTHCARE AND REHABILIT 23,303.51 0 161 13,217.73 3 080071600 HARMONY WEST DES MOINES 8,300.00 0 31 1,515.84 1 080072000 HARMONY UTICA RIDGE 0.00 0 18 0.00 1 080075100 GRANDVIEW CARE CENTER 6,782.40 0 28 1,185.00 1 080077500 NORTHGATE CARE CENTER 6,005.40 0 30 0.00 1 080077900 EMMETSBURG CARE CENTER 6,698.91 0 30 2,399.79 1 080078500 REHAB CENTER OF HAMPTON 12.97 0 1 244.64 1 080079100 GREATER SOUTHSIDE HEALTH AND REHABI 8,175.98 0 31 1,700.00 1 080131600 FRIENDSHIP HOME 412.75 0 5 1,025.55 1 080142300 GOOD SAMARITAN SOCIETY-DAVENPORT 0.00 0 20 0.00 1 080143100 GOOD SAMARITAN SOCIETY-ESTHERVILLE 26.00 0 0 0.00 1 080152200 GOOD SAMARITAN SOCIETY-OTTUMWA 7,021.28 0 28 1,157.24 1 080155500 GOOD SAMARITAN SOCIETY - ST ANSGAR 78.95 0 29 0.00 1 080159700 GOOD SAMARITAN SOCIETY-WEST UNION 28,900.30 3 94 0.00 1 080190200 HILLCREST HOME 7,726.00 0 25 0.00 1 080235500 LUTHERAN RETIREMENT HOME 31,686.13 0 107 1,907.59 2 080268600 METHODIST MANOR RETIREMENT COMM 18,292.07 0 61 0.00 1 080309800 PARKVIEW CARE CENTER 4,479.05 0 31 2,098.22 1 080340300 RIDGECREST VILLAGE 10,656.94 0 49 4,406.64 1 080355100 SALEM LUTHERAN HOMES 26.81 0 29 0.00 1 080357700 SCENIC MANOR 286.63 0 1 0.00 1 080473200 OAKWOOD CARE CENTER 4,980.16 0 30 3,080.24 1 080496300 ACCURA HEALTHCARE OF PLEASANTVILLE 6,204.40 0 31 1,701.53 1 080514300 ACCURA HEALTHCARE OF CHEROKEE 9,690.80 0 40 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 3 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 080515000 ACCURA HEALTHCARE OF SIOUX CITY 21,448.85 0 118 10,858.37 3 080532500 MONTEZUMA SPECIALTY CARE 3.02 0 10 0.00 1 080604200 IOWA VETERANS HOME 2,597,998.33 69 5,695 579,099.95 188 080797400 CENTERVILLE SPECIALTY CARE 6,543.00 0 25 0.00 1 080800600 AVOCA SPECIALTY CARE 3,045.79 0 19 1,978.00 1 080805500 LAPORTE CITY SPECIALTY CARE 14.08 0 0 0.00 1 080815400 HERITAGE SPECIALTY CARE 0.00 0 30 0.00 1 080818800 LYON SPECIALTY CARE 5,723.80 0 30 764.00 1 080820400 SOUTHRIDGE SPECIALTY CARE 8,032.50 0 44 267.75- 3 080825300 PARKRIDGE SPECIALTY CARE 8,941.56 0 4 1,666.64 2 080827900 RAVENWOOD SPECIALTY CARE 5,255.01 0 35 853.00 3 080832900 WESTWOOD SPECIALTY CARE 0.00 0 3 0.00 1 080901200 VISTA WOODS CARE CENTER 6,627.90 0 30 1,368.00 1 080905300 PRAIRIE RIDGE CARE CENTER 17,063.02 0 62 0.00 1 080962400 MISSISSIPPI VALLEY HEALTHCARE&REHAB 1,961.56 0 21 0.00 1 TOTAL: 3,198,164.97 72 8,558 681,989.40 271 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 4 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 554.00 0 60 1,702.00 2 011170800 PARK PLACE 643.14 0 90 2,740.86 3 011515400 CEDAR VALLEY RANCH 559.00 0 90 2,825.00 3 011623600 ANDREW JACKSON CARE 888.00 0 120 3,624.00 4 014759500 RINGGOLD CO GROUP HOME 287.00 0 30 841.00 1 030019700 HOPE HAVEN ADMIN 554.00 0 60 1,702.00 2 030025100 SCENIC ACRES 976.00 7 113 3,536.00 4 030030700 SUSAN HESPEN 303.75 1 29 824.25 1 030032800 RISE LTD 287.00 9 21 841.00 1 030039200 COMPREHENSIVE SYSTEMS 884.00 2 118 3,628.00 4 030053000 CEDAR VALLEY RANCH 3,686.00 15 330 9,286.00 12 030056100 PRIDE GROUP 3,411.02 3 387 11,205.40 8 030056600 PRAIRIE VIEW 447.00 0 60 1,809.00 2 030061600 MEDIAPOLIS CARE FACILITY 1,720.00 0 180 5,048.00 6 030061800 PENN CENTER INC 287.00 0 30 841.00 1 030064600 NORTH IOWA TRANSITIONAL CENTER 287.00 0 30 841.00 1 030067300 PARK PLACE 554.00 0 60 1,702.00 2 030070700 AREA RESIDENTIAL CARE 1,089.50 3 207 6,806.50 5 030084800 COUNTRY CARE CENTER CORP 193.12 0 30 934.88 1 030085500 CEDAR VALLEY RANCH 635.00 0 120 3,877.00 4 030086900 HILLCREST FAMILY SERVICES 302.60 1 30 863.00 1 030091900 PRIDE GROUP 1,948.40 0 170 4,428.00 6 030093900 ANDREW JACKSON CARE 608.40 0 119 3,866.00 6 030125900 NISHNA PRODUCTIONS RES COOR 283.10 0 30 844.90 1 030136600 RINGGOLD CO GROUP HOME 652.00 3 117 3,860.00 4 030149100 PATHWAYS 267.00 0 30 861.00 1 030170800 EYERLY BALL CMHS 267.00 0 30 861.00 1 030172900 WILLIAM DORRELL 1,128.00 0 30 0.00 1 030190300 PENN CENTER INC 1,815.00 10 260 8,337.00 9 030212600 MICHAEL HENNINGFIELD 596.20 0 17 43.00 1 030235000 PRIDE GROUP 287.00 0 30 841.00 1 030252000 HOWARD COLE 237.00 0 30 891.00 1 030263200 HORIZONS UNLIMITED 287.00 0 30 841.00 1 030284600 STEVEN CAREY 90.71 0 30 1,037.29 1 030294900 DAVID GIOVANNONI 22.00 0 30 1,106.00 1 030302100 KEVIN BANWART 338.63 0 31 802.79 1 030310900 BRIAN STEINFORD % CEDAR VALLEY RANC 129.74 1 29 998.26 1 030381200 TRAVIS BROWN 267.00 0 30 861.00 1 030382600 HANDICAPPED DEV CENTER 267.00 6 24 861.00 1 030406000 STEVEN STRAIGHT 267.00 0 30 861.00 1 030413800 ALAN CHAMBERS % COUNTRY CARE CTR 277.00 0 30 851.00 1 030425100 THOMAS FAULKNER 6.00 0 30 1,122.00 1 030459500 PRIDE GROUP 861.00 3 87 2,523.00 3 030463300 FRANCISCO GALVEZ % COMP SYSTEMS 237.83 0 30 890.17 1 030464300 ABBE CENTER FOR COMMUNITY MENTAL 5,604.60 20 641 19,249.00 21 030475000 THE PRIDE GROUP 118.00 2 28 1,010.00 1 030476500 HILLCREST 687.60 2 59 1,606.00 2 030487400 THE PRIDE GROUP 1,104.60 0 30 0.00 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 5 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 030492000 COMP SYSTEMS 434.40 4 25 656.00 1 030492900 NORTH IA TRANSITION CENT 1,129.60 4 132 3,984.00 3 030493500 PRIDE GROUP 595.00 0 60 1,661.00 2 030522100 GREGORY CASSI 275.12 0 30 852.88 1 030524800 HDC 554.00 0 60 1,702.00 2 030536000 ABBE 800.40 3 101 3,110.00 4 030550500 JULIA LINNANE 267.00 0 30 861.00 1 030552100 VF SHERIDAN SPRINGS 1,082.26 3 117 3,429.74 4 030552700 SHERIDAN SPRINGS 1,166.73 3 147 4,473.27 5 030557100 VERA FRENCH SHERIDAN SPRING 400.00 0 60 1,856.00 2 030558200 SHELLEY FIEDLER 267.00 0 30 861.00 1 030568200 NANCY NAILL 345.74 0 30 782.26 1 030576800 MARY J PARKIN 267.00 3 27 861.00 1 030578800 COUNTRY CARE 355.48 0 60 1,900.52 2 030587200 CEDAR VALLEY RANCH INC 376.00 2 58 1,880.00 2 030587400 ARCBEACON HILL RCF 147.00 0 30 981.00 1 030606900 ABBE CENTER BUS OFFICE 838.60 9 112 3,711.00 3 030612900 HORIZONS UNLIMITED OF PAC INC 1,898.52 8 107 2,425.48 4 030613600 ADELINE COMM. LIVING HOME 267.00 6 24 861.00 1 030614900 VERA FRENCH COMM MENTAL 823.77 0 120 3,688.23 4 030615300 BUNKER HILL COMMUNITY LIVING HOME 150.00 0 30 978.00 1 030615600 OPTIMAE LIFE SERVICES 287.00 0 30 841.00 1 030623200 OPTIMAE LIFE SERVICES 574.00 0 60 1,682.00 2 030646400 HORIZONS UNLIMITED 1,121.03 0 120 3,390.97 4 030678600 NINTH STREET GROUP HOME 287.00 6 54 1,969.00 2 030679100 ABBE CENTER FOR COMMUNITY MENTAL 993.00 1 119 3,519.00 4 030679200 THUNDERBIRD 948.40- 0 59 1,270.00- 1 030679300 HANDICAPPED DEV GRP HM #8 267.00 0 30 861.00 1 030680100 PRIDE IV 246.00 0 33 994.80 2 030680600 ABBE CENTER FOR CMH 267.00 0 30 861.00 1 030685400 PRIDE GROUP @ PRIMGHAR 717.00 3 87 2,667.00 3 030690000 KEYWAY COMMUNITY LIVING HOME 738.96 2 58 1,517.04 2 030690100 IMAGINE THE POSSIBILITIES INC 593.33 0 60 1,662.67 2 030690900 ABBE CENTER FOR CMH 433.00 0 70 2,199.00 3 030693100 ABBE CENTER FOR COMMUNITY MENTAL 174.20 0 27 841.00 1 030745400 NISHNA PRODUCTIONS 626.00 0 90 2,758.00 3 035515600 COMP SYSTEMS 1,199.77 7 141 4,365.03 5 036348100 PARK PLACE FOR 475.00 0 60 1,781.00 2 036377000 COUNTRY CARE CENTER 1,027.06 0 120 3,484.94 4 036800100 MAINSTREAM LIVING 1,165.60 0 121 3,384.00 3 038186300 KAIN RINEHART 571.60 0 60 1,661.00 1 038614400 RISE GROUP HOME 1,377.00 4 176 5,391.00 6 038899100 COMP SYSTEMS MARY A 229.40 0 29 861.00 1 039409800 PRIDE GROUP 321.42 0 31 820.00 1 040847600 PRIDE I 57.00 1 29 1,071.00 1 040965600 JOAN ROUTH 169.00 0 30 959.00 1 089002300 IMAGINE THE POSSIBILITIES INC 735.60 0 61 1,558.00 1 089006300 THUNDERBIRD 496.40 0 59 1,722.00 1 TOTAL: 63,844.53 157 7,343 217,997.13 244 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 6 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 63,149.44 0 30 68.06 1 TOTAL: 63,149.44 0 30 68.06 1 IAMG4100-R002 IOWA DEPARTMENT OF HUMAN SERVICES PAGE 7 AS OF 05/31/25 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 05/24/25 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 --------- ----------------------------------- --------------- ---------- ---------- --------------- ----------- 088025200 COURAGE HOMES 14,347.80 1 29 0.00 1 088026000 HILLS AND DALES 28,822.88 2 58 0.00 2 088036900 PARK VIEW HOMES 36,404.23 7 83 686.00 3 088063300 BLUFF VIEW HOMES 13,959.60 0 30 0.00 1 088068200 PROGRESS INDUSTRIES WEST 911.70 2 0 0.00 1 088081500 HACIENDA COMMUNITY LIVING HOME 28,796.65 5 55 0.00 2 088107800 WOODRIDGE HOUSE 14,478.90 0 30 0.00 1 088127600 BALANCE AUTISM 14,864.50 0 31 0.00 1 088142500 CHILDSERVE HOMES BEAVERDALE HOUSE 23,703.30 0 30 0.00 1 088148200 CHILDSERVE JOHNSTON DUPLEX SOUTH 14,501.40 0 30 0.00 1 088176300 BALANCE AUTISM YOUTH HOME 27,129.92 13 49 0.00 2 088203500 CHILDSERVE HOMES ANKENY TOWNHOME 13,368.70 0 30 1,132.70 1 088212600 CHILDSERVE HOMES ANKENY DUPLEX 14,501.40 0 30 0.00 1 088214200 CHILDSERVE HOMES MORNINGSIDE HOME 25,615.58 6 54 3,250.00 2 TOTAL: 271,406.56 36 539 5,068.70 20 ** END OF REPORT **