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

RECORD 1

Appendix A
CMS-304a

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

RECORD 2

MEDICAID DRUG REBATE
PRIOR QUARTER ADJUSTMENT STATEMENT
ELECTRONIC FORMAT

FIELD
Record ID
Labeler Code
Product/Package Code
Product Name
FSS/MCO Record ID
Original Rebate Per Unit
Current Rebate Per Unit
Original Units Invoiced
Current Units to Date
Prior Units Paid
Current Units Paid to Date
Prior Units Disputed
Current Units Disputed to Date
Original Amount Invoiced
Revised Invoice Amount
Prior Amount Paid
Current Amount Paid to Date
Amount Paid This Transaction
Adjustment Code(s)
Dispute Code(s)

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

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

RECORD 3

MEDICAID DRUG REBATE
PRIOR QUARTER ADJUSTMENT STATEMENT
ELECTRONIC FORMAT
FIELD
SIZE
Record ID
1
Labeler Code
5
Total Original Units Invoiced
12
Total Current Units to Date
12
Total Prior Units Paid
12
Total Current Units Paid to Date
12
Total Prior Units Disputed
12
Total Current Units Disputed to Date
12
Total Original Amount Invoiced
10
Total Revised Invoice Amount
10
Total Prior Amount Paid
10
Total Current Amount Paid to Date
10
Total Amount Paid This Transaction
10
Plus Interest Payment
8
Total Remittance
10

Appendix A
CMS-304a

REMARKS
Constant of “3”
NDC 1
Total for all NDCs 999999999V999
Total for all NDCs 999999999V999
Total for all NDCs 999999999V999
Total for all NDCs 999999999V999
Total for all NDCs 999999999V999
Total for all NDCs 999999999V999
Total for all NDCs 99999999V99
Total for all NDCs 99999999V99
Total for all NDCs 99999999V99
Total for all NDCs 99999999V99
Total for all NDCs 99999999V99
Total for all NDCs 999999V99
Total for all NDCs 99999999V99