Record Format: Crosswalk

CMS-R-144 State Invoice_Record Format_Crosswalk_12.2019.xlsx

Medicaid Drug Rebate Program (MDRP): Quarterly State Invoice (CMS-R-144) and State Agency Contact Form (CMS-368)

Record Format: Crosswalk

OMB: 0938-0582

Document [xlsx]
Download: xlsx | pdf
3/2019 (old version) 12/2019 (new version) Type of Change Reason for Change Burden Change

Package Size Code

Package Size
Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

Product FDA Red. Name

FDA Product Name
Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

Unit Rebate Amount

Unit Rebate Amount (URA)
Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

M'Caid Amount Reimb.

Medicaid Amount Reimbursed (MAR)
Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

Non M'Caid Amount Reimb.

Non-Medicaid Amount Reimbursed (NMAR)
Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

Total Amt Reimbursed

Total Amount Reimbursed (TAR)
Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

*Filler
Filler Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A

* Change to field
N/A Rev To align verbiage with other Medicaid Drug Rebate Program documentation. N/A
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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