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

PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS) INSTRUCTIONS
The PQAS (Form CMS-304a) is to be used to reconcile and explain prior quarter actions/payments/credits to
states.
Labelers use the PQAS in the following instances:
• When responding to the state’s invoice for unit changes for prior quarters
• When initially disputing invoiced units
• When reporting adjustments to prior rebate payments as a result of changes in pricing data (PPAs)
Labelers may submit the PQAS in hard copy form or electronically. However, if a state cannot accept an
electronic PQAS, we expect labelers to submit the PQAS in hard copy format.
The adjustment and dispute codes found in Appendix C are used for both the ROSI and PQAS. Labelers
should select at least one adjustment or dispute code per NDC, and may use several if necessary. Some codes
may be appropriate for either situation. In addition, some codes require supporting documentation; however,
supporting documentation can always be submitted, even for those instances where it is not specifically
mentioned.

PQAS Form (CMS-304a) Labeler Data Definitions
Data Fields
Labeler Name: Name of labeler as it appears on the signed rebate agreement. Alphanumeric, first 25 letters
of labeler name, left-justified, blank-filled.
Labeler Code: The first segment of the national drug code (NDC 1) as assigned by the FDA. Numeric only,
5 positions, right-justified, zero-filled.
Quarter Covered: Current quarter and year. Numeric, 5-digit field, QYYYY, no blanks.
Valid values for Q:
1 = January 1 - March 31
2 = April 1 - June 30
3 = July 1 - September 30
4 = October 1 - December 31
Valid values for YYYY: Four-digit calendar year covered.
Labeler Contact: Labeler’s Invoice contact. Alphabetic, 20-character field, left-justified, first name and last
name separated by 1 blank.
Phone: Labeler’s Invoice contact phone number. Numeric, 14-digit field, 10-digit area code and phone
number, and 4-digit extension or blanks.
Fax: Labeler’s Invoice contact fax number. Numeric, 10-digit field, area code and fax number.
State: State postal abbreviation. Alphabetic, 2-character field, no blanks.
Invoice Number: If no invoice number, blank-filled. Alphanumeric, 10-digit field, right-justified.
Date: Date ROSI was generated. Numeric only, 8-digit field, MMDDYYYY, no blanks.
Product/Package Code (Column A): The second and third segments of the NDC. Alphanumeric, 6-digit
field, right-justified, zero-filled.
Product Name (Column B): First 10 characters of product name as approved by and/or listed with the FDA.
Alphanumeric, 10-digit field, left-justified, blank-filled.
FSS/MCO Record ID (Column C): Constant of “FFSU” or “MCOU”: The FFSU Record ID indicates that
the information for this NDC represents a Fee-For Service record. The MCOU Record ID indicates that the
information for this NDC represents a Managed Care Organization record. 4-digit field, no blanks, valid
values: FFSU or MCOU.
Original Rebate Per Unit (Column D): CMS-calculated unit rebate amount (URA) as shown on the
original state invoice. Numeric, 11-digit field: 5 whole numbers and 6 decimals or zero-filled per invoice,
right-justified. 38

Current Rebate Per Unit (Column E): The adjusted/current URA. Numeric, 11-digit field: 5 whole
numbers and 6 decimals or blank-filled if not applicable, right-justified.
Original Units Invoiced (Column F): The number of units reported on the original invoice. Numeric, 12digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.
Current Units to Date (Column G): The number of units agreed upon by the labeler and state, as adjusted
from the original invoice. Numeric, 12-digit field, 9 whole numbers and 3 decimals, right-justified, zerofilled.
Prior Units Paid (Column H): The total units previously paid from the original invoice. Numeric, 12-digit
field: 9 whole numbers and 3 decimals, right-justified, zero-filled.
Current Units Paid to Date (Column I): The total units paid for this NDC with this PQAS. Numeric, 12digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.
Prior Units Disputed (Column J): The total units previously disputed from the original invoice. Numeric,
12-digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.
Current Units Disputed to Date (Column K): The total units disputed for this NDC, with this PQAS.
Numeric, 12-digit field: 9 whole numbers and 3 decimals, right-justified, zero-filled.
Original Amount Invoiced (Column L): The total rebate amount originally invoiced for this NDC.
Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.
Revised Invoice Amount (Column M): The total rebate amount as adjusted (where applicable) by this
PQAS for this NDC. Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.
Prior Amount Paid (Column N): The total amount previously paid for this NDC from the original invoice.
Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.
Current Amount Paid to Date (Column O): The total amount paid for this NDC, including payments
made via this PQAS. Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zero-filled.
Amount Paid This Transaction (Column P): The difference between columns M and N (the result may be
a positive or negative number). Numeric, 9-digit field: 7 whole numbers and 2 decimals, right-justified, zerofilled.
Adjustment Code(s) (Column Q): Adjustment explanation(s). Alphabetic, 3-character field. Valid values
per attached list of codes. Up to 3 Adjustment Codes per NDC; blanks for fewer than 3 codes.
Dispute Code(s) (Column R): Dispute explanation. Alphabetic only, 3-character field. Valid values per
attached list of codes. Up to 3 Adjustment Codes per NDC; blanks for fewer than 3 codes.
Totals (Bottom Row of Chart): Add totals for each column. Use parameters for each column total as
described for each field above.

Plus Interest Payment: Total amount of interest paid with this PQAS. Numeric, 8-digit field: 6 whole
numbers and 2 decimals, right-justified, zero-filled.
Total Remittance: Total rebate amount paid on this PQAS for all NDCs, including any interest payment.
Numeric, 10-digit field: 8 whole numbers and 2 decimals, right-justified, zero-filled.