CMS-304 Reconciliation of State Invoice (ROSI)

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MEDICAID DRUG REBATE

RECONCILIATION OF STATE INVOICE (ROSI)

LABELER NAME: ______________________________________ LABLER CONTACT: _______________________________________ STATE: _______________________________________

LABELER CODE: ______________________________________ _ PHONE: __________________________________________________ INVOICE NO. __________________________________

PERIOD COVERED: __________________________________ FAX: ____________________________________________________ DATE: _________________________________________

A

B

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D

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G

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I

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K

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PRODUCT/ PACKAGE CODE

PRODUCT NAME

FFS/MCO RECORD ID

UNIT REBATE AMOUNT

ADJUSTED UNIT REBATE AMOUNT

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. 06/30/2020) Plus Interest Payment

OMB No. 0938-0676 ===========

TOTAL REMITTANCE

Form CMS-304 (ROSI: Reconciliation of State Invoice) is used by manufacturers to respond to the state’s rebate invoice for current quarter utilization. The use of Form CMS-304 by manufacturers is considered mandatory under the authority of Section 1927 of the Social Security Act and the National Drug Rebate Agreement. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.

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.