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

RECONCILIATION OF STATE INVOICE (ROSI) INSTRUCTIONS

The ROSI (Form CMS-304) is to be used only to respond to the state’s invoice for current quarter utilization.

Labelers use the ROSI in the following instances:

• When disputing invoiced units.

• When the state invoice contains zero URAs.

Labelers must remit accurate rebate payments; therefore, the current URA must be applied to the units being paid. Labelers use the ROSI to report the correct URA to the state within 30 days of receiving the state’s current quarter invoice. In addition, labelers should send any pricing corrections to CMS.

Labelers may submit the ROSI in hard copy form or electronically. However, if a state cannot accept an electronic ROSI, we expect the labeler to submit it in a hard copy format.

The adjustment and dispute codes found in Appendix C are used for both the ROSI and the PQAS. We expect labelers to select at least one adjustment or dispute code per NDC, and labelers may use several if necessary. Some codes may be appropriate for either situation. In addition, some codes require supporting documentation; however, supporting documentation can always be submitted, even for those instances where it is not specifically mentioned.

RECONCILIATION OF STATE INVOICE

(Form CMS-304)

LABELER DATA DEFINITIONS

Data Fields

Labeler Name: Name of labeler as it appears on the signed rebate agreement. Alphanumeric, first 25 letters of labeler name, left-justified, blank-filled.

Labeler Code: The first segment of the national drug code (NDC 1) as assigned by the FDA. Numeric only, 5 positions, right-justified, zero-filled.

Quarter Covered: Current quarter and year. Numeric, 5-digit field, QYYYY, no blanks.

Valid values for Q:

1 = January 1 - March 31

2 = April 1 - June 30

3 = July 1 - September 30

4 = October 1 - December 31

Valid values for YYYY: Four-digit calendar year covered.

Labeler Contact: Labeler’s Invoice contact. Alphabetic, 20-character field, left-justified, first name and last name separated by 1 blank.

Phone: Labeler’s Invoice contact phone number. Numeric, 14-digit field, 10-digit area code and phone number, and 4-digit extension or blanks.

Fax: Labeler’s Invoice contact fax number. Numeric, 10-digit field, area code and fax number.

State: State postal abbreviation. Alphabetic, 2-character field, no blanks.

Invoice Number: If no invoice number, blank-filled. Alphanumeric, 10-digit field, right-justified.

Date: Date ROSI was generated. Numeric only, 8-digit field, MMDDYYYY, no blanks.

Product/Package Code (Column A): The second and third segments of the NDC. Alphanumeric, 6-digit field, right-justified, zero-filled.

Product Name (Column B): First 10 characters of product name as approved by and/or listed with the FDA. Alphanumeric, 10-digit field, left-justified, blank-filled.

FSS/MCO Record ID (Column C): Constant of “FFSU” or “MCOU”: The FFSU Record ID indicates that the information for this NDC represents a Fee-For-Service record. The MCOU Record ID indicates that the information for this NDC represents a Managed Care Organization record. 4-digit field, no blanks, valid values: FFSU or MCOU.

Rebate Per Unit (Column D: CMS-calculated unit rebate amount (URA) as shown on the state invoice. Numeric, 11-digit field: 5 whole numbers and 6 decimals or zero-filled per invoice, right-justified.

Adjusted Rebate Per Unit (Column E): URA if adjusted from the amount in the Rebate Per Unit field or blank if not applicable. (The Adjustment Code field must be annotated.) Numeric, 11-digit field: 5 whole numbers and 6 decimals, right-justified. Calculate to five decimals and round to four, pad positions 5 & 6 with zeros.

Units Invoiced (Column F): The total units reimbursed as shown on the invoice. Numeric, 12-digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.

Adjusted Units (Column G): Adjusted units preceded by a + or – based on labeler and state agreement. Annotate Adjustment Code field if adjusted units are present. Numeric, 13-digit field: 9 whole numbers and 3 decimals, right-justified, blank-filled if not applicable.

Labeler Disputed Units (Column H): Disputed units. Numeric, 12-digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.

Units Paid (Column I): Number of units paid after calculating adjustments and disputes. Numeric, 12-digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.

Adjustment Code(s) (Column J): Adjustment explanation(s). Alphabetic, 3-character field. Valid values per attached list of codes. Up to 3 Adjustment Codes per NDC; blanks for fewer than 3 codes.

Dispute Code(s) (Column K): Dispute explanation. Alphabetic only, 3-character field. Valid values per attached list of codes. Up to 3 Adjustment Codes per NDC; blank for fewer than 3 codes.

Rebate Amount Invoiced (Column L): The total rebate amount the state agency has billed the labeler for the period covered for this 11-digit NDC. Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.

Invoice Correction Amount (+ or -) (Column M): Adjusted invoice amount based on any adjustments or disputes. Numeric, preceded by a + or -, 10-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.

Withheld Invoice Amount (Column N): Rebate amount withheld based on any adjustments or disputes. Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.

Rebate Amount Paid (Column O): Total rebate amount paid for the NDC in the current quarter. Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.

Totals (Bottom Row of Chart): Add totals for each column. Use parameters for each column total as described for each field above.

Plus Interest Payment: Total amount of interest paid with this invoice. Numeric, 8-digit field: 6 whole numbers and 2 decimals, right-justified, zero-filled.

Total Remittance: Total rebate amount paid for all NDCs, including any interest payment. Numeric, 10-digit field: 8 whole numbers and 2 decimals, right-justified, zero-filled.