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

MEDICAID DRUG REBATE Appendix A RECONCILIATION OF STATE INVOICE CMS-304 ELECTRONIC FORMAT
RECORD 1	FIELD	SIZE	REMARKS
	Record ID	1	Constant of “1”
	Labeler 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
	FSS/MCO Record ID	4	Constant of “FFSU” or “MCOU”
	Rebate Per Unit	11	99999V999999
	Adjusted Rebate Per Unit	11	99999V999999
	Units Invoiced	12	999999999V999
	Adjusted Units (+/-)	13	9999999999V999
	Labeler Disputed Units	12	999999999V999
	Units Paid	12	999999999V999
	Adjustment Code(s)	3	See CMS-304, Appendix C
	Dispute Code(s)	3	See CMS-304, Appendix C
	Rebate Amount Invoiced	9	9999999V99
	Invoice Correction Amount (+/-)	10	99999999V99
	Withheld Invoice Amount	9	9999999V99
	Rebate Amount Paid	9	9999999V99

MEDICAID DRUG REBATE Appendix A RECONCILIATION OF STATE INVOICE CMS-304 ELECTRONIC FORMAT
RECORD 3	FIELD	SIZE	REMARKS
	Record ID	1	Constant of “3”
	Labeler Code	5	NDC 1
	Total Units Invoiced	12	999999999V999
	Total Adjusted Units (+/-)	13	9999999999V999
	Total Labeler Disputed Units	12	999999999V999
	Total Units Paid	12	999999999V999
	Total Rebate Amount Invoiced	10	99999999V99
	Total Invoice Correction Amt. (+/-)	11	999999999V99
	Total Withheld Invoice Amount	10	99999999V99
	Total Rebate Amount Paid	10	99999999V99
	Plus Interest Payment	8	999999V99
	Total Remittance	10	99999999V99