Form E-7 "New Jersey Acute Care Hospitals Cost Reports - Outpatient Gross Revenue by Payer and Outpatient Area" - New Jersey

What Is Form E-7?

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-7
2020
COST REPORTS
Hospital: __________________________________________
OUTPATIENT GROSS REVENUE
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
BY PAYER AND OUTPATIENT AREA
wording on this form.
($000’S)
A
B
C
D
E
F
G
H
I
J
K
L
Same
Off-Site
Outpatient
Same
(1)
Payer
Emergency
Private
Outpatient
Home
Other
Day
Health
Clinics
Dialysis
Day
MICU
TOTAL
Room
Referred
Surgery
Dialysis
MICU
Surgery
Services
Service
Psych.
1
Horizon Blue Cross of N. J. (Indemnity)
2
Other Blue Cross (Indemnity)
3
Medicare
(2)
4
Medicaid
(2)
5
CHAMPUS
6
HMO
7
Medicare HMO
8
Medicaid HMO
(3)
9
Commercial Insurers
10
Charity Care
11
Self-Pay
12
Others
13
Personnel Health
(1)
14
TOTALS
(1)
Total Line 14, Columns A through I should equal Form E, Page 2 of 2, Line 30, Columns B through G and I through K.
Total Line 14, Columns J and K should equal Form E, Page 2 of 2, Line 32, Columns B and C.
(2)
Do not include HMO revenue on lines 3 and 4.
(3)
Include indemnity (other than Blue Cross), and non-HMO managed care (e.g., preferred provider organizations; non-HMO point-of-service plans) on line 9.
NEW JERSEY ACUTE CARE HOSPITALS
E-7
2020
COST REPORTS
Hospital: __________________________________________
OUTPATIENT GROSS REVENUE
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
BY PAYER AND OUTPATIENT AREA
wording on this form.
($000’S)
A
B
C
D
E
F
G
H
I
J
K
L
Same
Off-Site
Outpatient
Same
(1)
Payer
Emergency
Private
Outpatient
Home
Other
Day
Health
Clinics
Dialysis
Day
MICU
TOTAL
Room
Referred
Surgery
Dialysis
MICU
Surgery
Services
Service
Psych.
1
Horizon Blue Cross of N. J. (Indemnity)
2
Other Blue Cross (Indemnity)
3
Medicare
(2)
4
Medicaid
(2)
5
CHAMPUS
6
HMO
7
Medicare HMO
8
Medicaid HMO
(3)
9
Commercial Insurers
10
Charity Care
11
Self-Pay
12
Others
13
Personnel Health
(1)
14
TOTALS
(1)
Total Line 14, Columns A through I should equal Form E, Page 2 of 2, Line 30, Columns B through G and I through K.
Total Line 14, Columns J and K should equal Form E, Page 2 of 2, Line 32, Columns B and C.
(2)
Do not include HMO revenue on lines 3 and 4.
(3)
Include indemnity (other than Blue Cross), and non-HMO managed care (e.g., preferred provider organizations; non-HMO point-of-service plans) on line 9.