Form E-4 "New Jersey Acute Care Hospitals Cost Reports - Gross Revenue and Deductions From Gross Revenue" - New Jersey

What Is Form E-4?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

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NEW JERSEY ACUTE CARE HOSPITALS
E-4
2020
COST REPORTS
Hospital: __________________________________________
Do not change any preprinted
GROSS REVENUE AND DEDUCTIONS
Hospital Number: |_____|_____|_____|_____|
wording on this form.
FROM GROSS REVENUE ($000’S)
A
B
C
D
E
Skilled
Services
Net Total
Total
Nursing
Not Related to
MICU
Column A Minus
Facility
Patient Care (1)
Columns B, C, D
1
Gross Revenue from Patient Care
ALLOWANCES AND ADJUSTMENTS
2
Allowances and Adjustments – Prior Period
3
Current Year Allowances, Include Medicare Current Year Allowances
4
Other Uncompensated Care Subsidy (Medicare)
(
)
/ / / / / / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(
)
5
Other Subsidies (Incl. Hospital Relief Fund and Mental Health Subsidies)
(
)
/ / / / / / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(
)
6
Prompt Payment Discount
7
Personnel Health Allowances
8
Courtesy Adjustments
9
Other Administrative Adjustments
10
Total Allowances and Adjustments (Lines 2 through 9)
MEDICAL DENIALS
11
Medical Denials
12
Nursing Home Placement
Days
13
Total (Lines 11 and 12)
UNCOMPENSATED CARE
14
Charity Care
15
Grants and Payments for Indigency
(
)
(
)
(
)
(
)
(
)
16
Bad Debt Provisions
17
Bad Debt Recoveries, Include SOIL Recoveries
(
)
(
)
(
)
(
)
(
)
18
Charity Care Subsidy
(
)
/ / / / / / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(
)
19
Total Net Uncompensated Care (Lines 14 through 18)
20
Total Deductions from Gross Revenue (Lines 10 + 13 + 19)
(1) This includes but is not limited to items covered under NJAC 8:31B-4.61 , 4.62, 4.64, and 4.65.
NEW JERSEY ACUTE CARE HOSPITALS
E-4
2020
COST REPORTS
Hospital: __________________________________________
Do not change any preprinted
GROSS REVENUE AND DEDUCTIONS
Hospital Number: |_____|_____|_____|_____|
wording on this form.
FROM GROSS REVENUE ($000’S)
A
B
C
D
E
Skilled
Services
Net Total
Total
Nursing
Not Related to
MICU
Column A Minus
Facility
Patient Care (1)
Columns B, C, D
1
Gross Revenue from Patient Care
ALLOWANCES AND ADJUSTMENTS
2
Allowances and Adjustments – Prior Period
3
Current Year Allowances, Include Medicare Current Year Allowances
4
Other Uncompensated Care Subsidy (Medicare)
(
)
/ / / / / / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(
)
5
Other Subsidies (Incl. Hospital Relief Fund and Mental Health Subsidies)
(
)
/ / / / / / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(
)
6
Prompt Payment Discount
7
Personnel Health Allowances
8
Courtesy Adjustments
9
Other Administrative Adjustments
10
Total Allowances and Adjustments (Lines 2 through 9)
MEDICAL DENIALS
11
Medical Denials
12
Nursing Home Placement
Days
13
Total (Lines 11 and 12)
UNCOMPENSATED CARE
14
Charity Care
15
Grants and Payments for Indigency
(
)
(
)
(
)
(
)
(
)
16
Bad Debt Provisions
17
Bad Debt Recoveries, Include SOIL Recoveries
(
)
(
)
(
)
(
)
(
)
18
Charity Care Subsidy
(
)
/ / / / / / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(
)
19
Total Net Uncompensated Care (Lines 14 through 18)
20
Total Deductions from Gross Revenue (Lines 10 + 13 + 19)
(1) This includes but is not limited to items covered under NJAC 8:31B-4.61 , 4.62, 4.64, and 4.65.