Prior Quarter Adjustment Statement (PQAS, CMS-304A)

Appendix C
CMS-304 & 304a
Adjustment/Dispute Codes for Reconciliation of State Invoice (CMS-304) and/or Prior Quarter
Adjustment Statement (CMS-304a)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
X.

Rebate per unit (RPU) amount has been revised by labeler and reported to CMS, as required.
Labeler has calculated RPU and/or rebate where none was reported by state.
Units invoiced adjusted through mutual agreement between labeler/state.
Labeler/state Unit Type and/or Units Per Package Size (UPPS) value discrepancy (e.g., unit type and/or UPPS reported
on invoice does not match CMS tape).
Labeler/state decimal discrepancy or rounding problems (e.g., state invoice does not reflect decimal value on CMS tape).
*Package size discrepancy (e.g., could include correction to package size by labeler).
*Transferred NDC to another labeler code (Labeler code is ultimately responsible for rebate payment).
Utilization change from the State.
RPU amount adjusted through correspondence between labeler/State. USE THIS CODE ONLY when the State has
reported a RPU not based on the CMS tape and code A is not applicable.
No state reimbursement reflected on claims level detail.
*J-Code to NDC crosswalk requires validation data (e.g., crosswalk to products with multiple NDCs and/or package
sizes).
Generic Substitution.
Duplicate Claim.
*Discontinued/terminated NDC for which the shelf life expired more than one year from the dispense date
(Documentation should support dispensed date).
Invalid/miscoded NDC.
*State units invoiced exceed unit sales (Documentation should include supporting methodology and data source).
Utilization/quantity is inconsistent with the number of prescriptions.
*Utilization/quantity is inconsistent with pharmacy reimbursement levels, including Third Party Payments (This dispute
code should be used in conjunction with another code or other supporting documentation).
*Utilization/quantity is inconsistent with State historical trends or current State program information (Documentation
should include trend/program information).
Utilization/quantity is inconsistent with lowest dispensable package size.
*Product not rebate-eligible (e.g., product was not reported to CMS because product is not a covered outpatient drug,
product is for a non-Medicaid State-only program, an HMO non-fee-for-service program, etc…).
*No record of sales directly to State or State history of purchase from out-of-State provider (e.g., border pharmacies,
mail order pharmacies, etc…).
Closed out. All disputes resolved.
*PHS entity not extracted from State data (Documentation should include PHS provider number).

*Supporting Documentation REQUIRED.
Note: Some adjustment/dispute codes are specifically noted to require supporting documentation; however, supporting documentation can always be
submitted, even for those instances where it is not specifically mentioned on this document.