Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304)

Appendix C

CMS-304 & 304a

Adjustment/Dispute Codes* for

Reconciliation of State Invoice and/or Prior Quarter Adjustment Statement

Adjustment Codes

A. Rebate per unit amount has been revised by labeler and reported to CMS, as required.

B. Labeler has calculated RPU and/or rebate where none was reported by state.

C. Units invoiced adjusted through mutual agreement between labeler/state.

D. Package size discrepancies.

E. Units overstated.

F. Labeler/State Unit Type discrepancy (e.g., GM vs ML).

G. Labeler/State Units Per Package Size decimal discrepancy (e.g., rounding to whole unit issues or instances whereby a decimal can’t be split).

H. Converted NDC (e.g., package size correction). (Please attach supporting documentation.)

I. Transferred NDC to another labeler code (Please attach supporting documentation).

J. Utilization change from the State.

K. Rebate per unit amount adjusted through correspondence between labeler/State. USE THIS CODE ONLY when the State has reported a rebate per unit not based on the CMS tape and adjustment code A is not applicable.

Dispute Codes

A. Discontinued/Terminated NDC for which the shelf life expired more than one year ago from the dispense date.

B. Invalid/miscoded NDC.

C. State units invoiced exceed unit sales (Please attach supporting methodology and data source).

D. Utilization/quantity is inconsistent with the number of prescriptions.

E. Utilization/quantity is inconsistent with pharmacy reimbursement levels, including Third Party Payments (This dispute code must be used in conjunction with another code or other supporting documentation).

F. Utilization/quantity is inconsistent with State historical trends or current State program information (Please attach trend/program information).

G. Utilization/quantity is inconsistent with lowest dispensable package size.

H. Product not rebate eligible (e.g., product is for a non-Medicaid State-only program, an HMO non-fee-for-service program, etc…). (Please attach supporting documentation.)

I. No record of sales directly to State or State history of purchase from out-of-State provider (e.g., border pharmacies, mail order pharmacies, etc…). (Please attach supporting documentation.)

J. PHS entity not extracted from State data (Please give provider number).

K. Duplicate Claim.

L. Generic Substitution.

M. Closed out. All disputes resolved.

F53

* Some adjustment/dispute codes are specifically noted to require supporting documentation; however, supporting documentation can always be submitted, even for those instances where it is not specifically mentioned on this document.