Form CMS-304a Prior Quarter Adjustment Statement (PQAS)

PAGE_____Of______
MEDICAID DRUG REBATE

PRIOR QUARTER ADJUSTMENT STATEMENT
(for reconciling unit changed, disputed units, and PPAs)

LABELER NAME: ______________________________________

LABLER CONTACT: _______________________________________

STATE: _______________________________________

LABELER CODE: _______________________________________

PHONE: __________________________________________________

INVOICE NO. __________________________________

QUARTER COVERED: __________________________________

FAX: ____________________________________________________

DATE: _________________________________________

A
PRODUCT/
PACKAGE
CODE

B
PRODUCT
NAME

C
FFS/MCO
RECORD ID

D

E

ORIGINAL CURRENT
REBATE
REBATE
PER UNIT PER UNIT

F
ORIGINAL
UNITS
INVOICED

G

H

CURRENT
UNITS
TO DATE

PRIOR
UNITS
PAID

I
CURRENT
UNITS PAID
TO DATE

J
PRIOR
UNITS
DISPUTED

K

CURRENT
UNITS
DISPUTED
TO DATE

L

M

ORIGINAL
AMOUNT
INVOICED

REVISED
INVOICE
AMOUNT

N

O

P

Q

PRIOR
CURRENT AMT PAID
ADJM
AMOUNT AMT PAID
THIS
PAID
TO DATE
TRANS
CODE

R
DISP
CODE

TOTALS
CMS-304a (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 28 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.