Form E-6 "New Jersey Acute Care Hospitals Cost Reports - Net Outpatient Revenue Summary" - New Jersey

What Is Form E-6?

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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Download Form E-6 "New Jersey Acute Care Hospitals Cost Reports - Net Outpatient Revenue Summary" - New Jersey

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NEW JERSEY ACUTE CARE HOSPITALS
2020
E-6
COST REPORTS
Hospital: __________________________________________
NET OUTPATIENT REVENUE
Do not change any preprinted
SUMMARY
wording on this form.
Hospital Number: |_____|_____|_____|_____|
($000’S)
A
B
C
D
E
F
G
H
I
J
K
L
M
NOTE: Only include items as
Horizon
Other
Medicare
Medicaid
Commercial
Charity
Self
Reported in Column E of Form E-4
(2)
(2)
(1)
Blue Cross
Blue Cross
Medicare
Medicaid
CHAMPUS
HMO
Others
TOTAL
(3)
HMO
HMO
Insurance
Care
Pay
(Indemnity)
(Indemnity)
1
Gross Revenue from Patient Care
ALLOWANCES AND ADJUSTMENTS
2
Allowances and Adjustments-Prior Year
3
Current Year Allowances-(Incl. Medicare C/Y)
4
Other Uncomp. Care Subsidy (Medicare)
/ / / / / / / /
/ / / / / / / /
(
)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
(
)
5
Other Subsidies (Excl. Amts.on Lines 4 & 18)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
6
Prompt Payment Discount
7
Personnel Health Allowances
8
Courtesy Adjustments
9
Other Administrative Adjustments
10
Total Allowances and Adjustments
MEDICAL DENIALS
11
Medical Denials
12
Nursing Home Placement
13
Total (Lines 11 and 12)
UNCOMPENSATED CARE
14
Charity Care
15
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
Grants and Payments for Indigency
16
Bad Debt Provision
17
Bad Debt Recoveries (Inc. SOIL Recoveries)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
18
Charity Care Subsidy
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
19
Total Uncomp. Care (Lines 14,15,16,17,18)
20
Total Deductions from Gross Revenue
(1) The sum of Forms E-5 and E-6, Column M, should agree with Form E-4, Column E, for all lines.
(2) Do not include HMO revenue in columns C and D.
(3) Include indemnity (other than Blue Cross), and non-HMO managed care (e.g., preferred provider organizations; non-HMO point of service plans) in Column I.
NEW JERSEY ACUTE CARE HOSPITALS
2020
E-6
COST REPORTS
Hospital: __________________________________________
NET OUTPATIENT REVENUE
Do not change any preprinted
SUMMARY
wording on this form.
Hospital Number: |_____|_____|_____|_____|
($000’S)
A
B
C
D
E
F
G
H
I
J
K
L
M
NOTE: Only include items as
Horizon
Other
Medicare
Medicaid
Commercial
Charity
Self
Reported in Column E of Form E-4
(2)
(2)
(1)
Blue Cross
Blue Cross
Medicare
Medicaid
CHAMPUS
HMO
Others
TOTAL
(3)
HMO
HMO
Insurance
Care
Pay
(Indemnity)
(Indemnity)
1
Gross Revenue from Patient Care
ALLOWANCES AND ADJUSTMENTS
2
Allowances and Adjustments-Prior Year
3
Current Year Allowances-(Incl. Medicare C/Y)
4
Other Uncomp. Care Subsidy (Medicare)
/ / / / / / / /
/ / / / / / / /
(
)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
(
)
5
Other Subsidies (Excl. Amts.on Lines 4 & 18)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
6
Prompt Payment Discount
7
Personnel Health Allowances
8
Courtesy Adjustments
9
Other Administrative Adjustments
10
Total Allowances and Adjustments
MEDICAL DENIALS
11
Medical Denials
12
Nursing Home Placement
13
Total (Lines 11 and 12)
UNCOMPENSATED CARE
14
Charity Care
15
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
Grants and Payments for Indigency
16
Bad Debt Provision
17
Bad Debt Recoveries (Inc. SOIL Recoveries)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
18
Charity Care Subsidy
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
19
Total Uncomp. Care (Lines 14,15,16,17,18)
20
Total Deductions from Gross Revenue
(1) The sum of Forms E-5 and E-6, Column M, should agree with Form E-4, Column E, for all lines.
(2) Do not include HMO revenue in columns C and D.
(3) Include indemnity (other than Blue Cross), and non-HMO managed care (e.g., preferred provider organizations; non-HMO point of service plans) in Column I.