Information Collection

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

IC 46422 under ICR 201107-0938-007 · OMB 0938-0676.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0676 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-304a Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)	Form
Instructions for CMS-304a PQAS_Final_2011.doc	Instruction
Appendix A for CMS-304a_Final_ 2011.doc	Other-Appendix
Appendix C for CMS-304 & 304a_2011.doc	Other-Appendix
CMS-304a Prior Quarter Adjustment Statement (PQAS) PQAS Form with Disclosure Statement_2011.pdf	Form
CMS-304a - Appendix A Crosswalk [rev 07-19-11].doc Crosswalk - Appendix A (CMS-304a)	IC Document
CMS-304a Instructions - Crosswalk [rev 07-19-11].doc Crosswalk - Instructions (CMS-304a)	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-304a	Prior Quarter Adjustment Statement (PQAS)	PQAS Form with Disclosure Statement_2011.pdf	Yes	Yes	Fillable Fileable
Instruction			Instructions for CMS-304a PQAS_Final_2011.doc	Yes	No	Printable Only
Other-Appendix			Appendix A for CMS-304a_Final_ 2011.doc	Yes	No	Printable Only
Other-Appendix			Appendix C for CMS-304 & 304a_2011.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 595

Number of Respondents for Small Entity: 60

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	2,380	100	2,280
Annual IC Time Burden (Hours)	66,640	21,040	45,600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Appendix A (CMS-304a)	CMS-304a - Appendix A Crosswalk [rev 07-19-11].doc	07/19/2011
Crosswalk - Instructions (CMS-304a)	CMS-304a Instructions - Crosswalk [rev 07-19-11].doc	07/19/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.