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

Reconciliation of State Invoice (ROSI) (CMS-304) and Prior Quarter Adjustment Statement (PQRS) (CMS-304a)

CMS-304a Prior Quarter Adjustment Statement (PQAS)_2019_Final

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

OMB: 0938-0676

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MEDICAID DRUG REBATE

PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS)

(for reconciling unit changed, disputed units, and PPAs)




LABELER NAME: ______________________________________ LABLER CONTACT: _______________________________________ STATE: _______________________________________


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


PERIOD COVERED: __________________________________ FAX: ____________________________________________________ DATE: _________________________________________


A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

PRODUCT/

PACKAGE

CODE

PRODUCT

NAME

FFS/MCO

RECORD ID

ORIGINAL UNIT REBATE

AMOUNT

CURRENT

UNIT REBATE

AMOUNT

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 AMT PAID TO DATE

AMT PAID THIS TRANS

ADJM CODE

DISP CODE























































































































































































































































































































































TOTALS



















CMS-304a (Exp. 06/30/2020) Plus Interest Payment

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

TOTAL REMITTANCE


Form CMS-304a (PQAS: Prior Quarter Adjustment Statement) is required for manufacturers only in those instances where a change to an original quarterly rebate data submittal is necessary.  When needed, the use of Form CMS-304a 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 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.

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AuthorCMS
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