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

MEDICAID DRUG REBATE Appendix A PRIOR QUARTER ADJUSTMENT STATEMENT CMS-304a ELECTRONIC FORMAT
RECORD 1	FIELD	SIZE	REMARKS
	Record ID	1	Constant of “1”
	Company Name	25	First 25 Positions of Company Name
	Labeler Code	5	NDC #1
	Quarter Covered	5	QYYYY
	Labeler Contact	20	Labeler’s Contact Person
	Phone	14	Area Code/Phone No./Ext. of Contact
	Fax	10	Labeler’s Contact Fax Number
	State	2	Two Position Postal Abbreviation
	Invoice Number	10	Corresponds to State Invoice Number
	Date	8	Date Report was Created
RECORD 2	FIELD	SIZE	REMARKS
	Record ID	1	Constant of “2”
	Labeler Code	5	NDC #1
	Product/Package Code	6	NDC #2 and #3
	Product Name	10	First 10 Positions of Product Name
	Original Rebate Per Unit	11	99999V999999
	Current Rebate Per Unit	11	99999V999999
	Original Units Invoiced	12	999999999V999
	Current Units to Date	12	999999999V999
	Prior Units Paid	12	999999999V999
	Current Units Paid to Date	12	999999999V999
	Prior Units Disputed	12	999999999V999
	Current Units Disputed to Date	12	999999999V999
	Original Amount Invoiced	9	9999999V99
	Revised Invoice Amount	9	9999999V99
	Prior Amount Paid	9	9999999V99
	Current Amount Paid to Date	9	9999999V99
	Amount Paid This Transaction	9	9999999V99
	Adjustment Code(s)	3	See HCFA-304a, Appendix C
	Dispute Code(s)	3	See HCFA-304a, Appendix C

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MEDICAID DRUG REBATE Appendix A PRIOR QUARTER ADJUSTMENT STATEMENT CMS-304a ELECTRONIC FORMAT
RECORD 3	FIELD	SIZE	REMARKS
	Record ID	1	Constant of “3”
	Labeler Code	5	NDC #1
	Total Original Units Invoiced	12	Total for all NDCs 999999999V999
	Total Current Units to Date	12	Total for all NDCs 999999999V999
	Total Prior Units Paid	12	Total for all NDCs 999999999V999
	Total Current Units Paid to Date	12	Total for all NDCs 999999999V999
	Total Prior Units Disputed	12	Total for all NDCs 999999999V999
	Total Current Units Disputed to Date	12	Total for all NDCs 999999999V999
	Total Original Amount Invoiced	10	Total for all NDCs 99999999V99
	Total Revised Invoice Amount	10	Total for all NDCs 99999999V99
	Total Prior Amount Paid	10	Total for all NDCs 99999999V99
	Total Current Amount Paid to Date	10	Total for all NDCs 99999999V99
	Total Amount Paid This Transaction	10	Total for all NDCs 99999999V99
	Plus Interest Payment	8	Total for all NDCs 999999V99
	Total Remittance	10	Total for all NDCs 99999999V99

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