CMS-304 Reconciliation of State Invoice

MEDICAID DRUG REBATE

PAGE _______ OF _______

RECONCILIATION OF STATE INVOICE

LABELER NAME ______________________________________ LABELER CONTACT ________________________________ STATE _____________________________________

LABELER CODE ______________________________________ PHONE __________________________________ INVOICE NO. _______________________________

QUARTER COVERED ____________________________________ FAX ____________________________________ DATE ______________________________________

A

B

C

D

E

F

G

H

I

J

K

L

M

N

INVOICE

PRODUCT/

ADJUSTED

ADJUSTED

LABELER

REBATE

CORRECTION

WITHHELD

REBATE

PACKAGE

PRODUCT

REBATE

REBATE

UNITS

UNITS

DISPUTED

UNITS

ADJM

DISP

AMOUNT

AMOUNT

INVOICE

AMOUNT

CODE

NAME

PER UNIT

PER UNIT

INVOICED

+ or -

UNITS

PAID

CODE

CODE

INVOICED

+ or -

AMOUNT

PAID

TOTALS

Plus Interest Payment

CMS-304 (Exp.)

TOTAL REMITTANCE

OMB No. 0938-0676

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0676.

The time required to complete this information collection is estimated to average 62 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection.

If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.