Form B-5 "New Jersey Acute Care Hospitals Cost Reports - Other Statistical Data (Excluding Snf)" - New Jersey

What Is Form B-5?

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 a fillable version of Form B-5 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form B-5 "New Jersey Acute Care Hospitals Cost Reports - Other Statistical Data (Excluding Snf)" - New Jersey

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NEW JERSEY ACUTE CARE HOSPITALS
2020
COST REPORTS
OTHER STATISTICAL DATA (EXCLUDING SNF)
Hospital: __________________________________________
B-5
Hospital Number: |_____|_____|_____|_____|
A
B
PATIENT
(1)
INPATIENT STATISTICS BY PAYER
ADMISSIONS
DAYS
(Do Not Combine Payer Categories)
1
Horizon Blue Cross of New Jersey (Indemnity)
2
Other Blue Cross (Indemnity)
3
Medicare
(2)
(2)
4
Medicaid
5
CHAMPUS
6
HMO
7
Medicare HMO
8
Medicaid HMO
9
Commercial Insurers
(3)
10
Charity Care
11
Self Pay
(4)
12
Others (Identify)
(5)
13
Personnel Health
14
TOTALS – Form B Totals Less SNF (Col. L MINUS Col. I)
OTHER STATISTICAL DATA
15
Cafeteria Average Meal Price
16
Estimated Annual Free Meals to All Employees
17
Estimated Annual Free Meals to All Students
18
Estimated Annual Free Meals to All Others
(1)
Do not combine lines. Data should be reported for every line.
(2)
Do not include HMO admissions or patient days 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.
(4)
If more than one payer, provide detail by payer on separate schedule. Include other government.
(5)
Hospital employees whose entire medical expenses have been paid by the hospital.
NEW JERSEY ACUTE CARE HOSPITALS
2020
COST REPORTS
OTHER STATISTICAL DATA (EXCLUDING SNF)
Hospital: __________________________________________
B-5
Hospital Number: |_____|_____|_____|_____|
A
B
PATIENT
(1)
INPATIENT STATISTICS BY PAYER
ADMISSIONS
DAYS
(Do Not Combine Payer Categories)
1
Horizon Blue Cross of New Jersey (Indemnity)
2
Other Blue Cross (Indemnity)
3
Medicare
(2)
(2)
4
Medicaid
5
CHAMPUS
6
HMO
7
Medicare HMO
8
Medicaid HMO
9
Commercial Insurers
(3)
10
Charity Care
11
Self Pay
(4)
12
Others (Identify)
(5)
13
Personnel Health
14
TOTALS – Form B Totals Less SNF (Col. L MINUS Col. I)
OTHER STATISTICAL DATA
15
Cafeteria Average Meal Price
16
Estimated Annual Free Meals to All Employees
17
Estimated Annual Free Meals to All Students
18
Estimated Annual Free Meals to All Others
(1)
Do not combine lines. Data should be reported for every line.
(2)
Do not include HMO admissions or patient days 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.
(4)
If more than one payer, provide detail by payer on separate schedule. Include other government.
(5)
Hospital employees whose entire medical expenses have been paid by the hospital.