Reconciliation of State Invoice (ROSI, CMS-304)

RECORD 2

RECORD 1

MEDICAID DRUG REBATE
RECONCILIATION OF STATE INVOICE
ELECTRONIC FORMAT

Appendix A
CMS-304

FIELD
Record ID
Labeler Name
Labeler Code
Quarter Covered
Labeler Contact
Phone
Fax
State
Invoice Number
Date

SIZE
1
25
5
5
20
14
10
2
10
8

REMARKS
Constant of “1”
First 25 Positions of Company Name
NDC 1
QYYYY
Labeler’s Contact Person
Area Code/Phone No./Ext. of Contact
Labeler’s Contact Fax Number
Two Position Postal Abbreviation
Corresponds to State Invoice Number
Date Report was Created

FIELD
Record ID
Labeler Code
Product/Package Code
Product Name
FSS/MCO Record ID
Rebate Per Unit
Adjusted Rebate Per Unit
Units Invoiced
Adjusted Units (+/-)
Labeler Disputed Units
Units Paid
Adjustment Code(s)
Dispute Code(s)
Rebate Amount Invoiced
Invoice Correction Amount (+/-)
Withheld Invoice Amount
Rebate Amount Paid

SIZE
1
5
6
10
4
11
11
12
13
12
12
3
3
9
10
9
9

REMARKS
Constant of “2”
NDC 1
NDC 2 and 3
First 10 Positions of Product Name
Constant of “FFSU” or “MCOU”
99999V999999
99999V999999
999999999V999
9999999999V999
999999999V999
999999999V999
See CMS-304, Appendix C
See CMS-304, Appendix C
9999999V99
99999999V99
9999999V99
9999999V99

RECORD 3

MEDICAID DRUG REBATE
RECONCILIATION OF STATE INVOICE
ELECTRONIC FORMAT
FIELD
Record ID
Labeler Code
Total Units Invoiced
Total Adjusted Units (+/-)
Total Labeler Disputed Units
Total Units Paid
Total Rebate Amount Invoiced
Total Invoice Correction Amt. (+/-)
Total Withheld Invoice Amount
Total Rebate Amount Paid
Plus Interest Payment
Total Remittance

SIZE
1
5
12
13
12
12
10
11
10
10
8
10

REMARKS
Constant of “3”
NDC 1
999999999V999
9999999999V999
999999999V999
999999999V999
99999999V99
999999999V99
99999999V99
99999999V99
999999V99
99999999V99

Appendix A
CMS-304