CMS-304 Reconciliation of State Invoice (ROSI)

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MEDICAID DRUG REBATE

RECONCILIATION OF STATE INVOICE

LABELER NAME: ______________________________________

LABLER CONTACT: _______________________________________

STATE: _______________________________________

LABELER CODE: _______________________________________

PHONE: __________________________________________________

INVOICE NO. __________________________________

QUARTER COVERED: __________________________________

FAX: ____________________________________________________

DATE: _________________________________________

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

PRODUCT/
PACKAGE
CODE

PRODUCT
NAME

FFS/MCO
RECORD ID

REBATE
PER UNIT

ADJUSTED
REBATE
PER UNIT

UNITS
INVOICED

ADJUSTED
UNITS
+ or -

LABELER
DISPUTED
UNITS

UNITS
PAID

ADJM
CODE

DISP
CODE

REBATE
AMOUNT
INVOICED

INVOICE
CORRECTION
AMOUNT

WITHELD
INVOICE
AMOUNT

REBATE
AMOUNT
PAID

TOTALS
CMS-304 (Exp. TBD)
OMB No. 0938-0676

Plus Interest Payment
===========

TOTAL REMITTANCE
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid control number for this information collection is 0938-0676. The time
required to complete this information collection is estimated to average 70 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland, 21244-1850.