State Drug Rebate (Medicaid)

State Drug Rebate (Medicaid) (CMS-368 and R-144)

ACA Record Layout_Final_2011

State Drug Rebate (Medicaid)

OMB: 0938-0582

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MEDICAID DRUG REBATE PROGRAM

STATE INVOICE RECORD FORMAT

(Form CMS-R-144)

Effective: December 1, 2011


Source: State Agencies

Target: CMS & Manufacturers


Field


Size


Position


Remarks


*Record ID


4


1 – 4


Constant of “FFSU” or “MCOU”


State Code


2


5 – 6


P.O. Abbreviation


Labeler Code


5


7 – 11


NDC 1


Product Code


4


12 – 15


NDC 2


Package Size Code


2


16 – 17


NDC 3


Period Covered


5


18 – 22


QYYYY


Product FDA Reg. Name


10


23 – 32


Product name as appears on FDA listing form.

(1st 10 characters)


Unit Rebate Amount


12


33 – 44


9(5).9(6)


Units Reimbursed


15


45 – 59


9(11).999


Rebate Amount Claimed


12


60 – 71


9(9).99


Number of Prescriptions


8


72 – 79


9(8)

M’Caid Amount Reimb.


13


80 – 92


9(10).99


Non-M’Caid Amount Reimb.


13


93 - 105


9(10).99


Total Amt Reimbursed


14


106 – 119


9(11).99






*Filler






1






120 – 120










All fields with decimals now require actual decimal

* Change to field


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMEDICAID DRUG REBATE PROGRAM
AuthorCMS
File Modified0000-00-00
File Created2021-01-31

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