Track Change - Electronic Format

ROSI Electronic Format for CMS-304_2019_TC.docx

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

Track Change - Electronic Format

OMB: 0938-0676

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MEDICAID DRUG REBATE

RECONCILIATION OF STATE INVOICE (ROSI) CMS-304

ELECTRONIC FORMAT

RECORD 1

FIELD

SIZE

REMARKS

Record ID

1

Constant of “1”

Labeler Name

25

First 25 Positions of Company Name

Labeler Code

5

NDC 1

Period Covered

5

QYYYY

Labeler Contact

20

Labeler’s Contact Person

Phone

14

Area Code/Phone No./Ext. of Contact

Fax

10

Labeler’s Contact Fax Number

State Code

2

Two Position Postal Abbreviation

Invoice Number

10

Corresponds to State Invoice Number

Date

8

Date Report was Created




RECORD 2

FIELD

SIZE

REMARKS

Record ID

1

Constant of “2”

Labeler Code

5

NDC 1

Product Code/Package

6

NDC 2 and 3

FDA Product Name

10

First 10 Positions of Product Name

FFS/MCO Record ID

4

Constant of “FFSU” or “MCOU”

Unit Rebate Amount

11

99999V999999

Adjusted Unit Rebate Amount

11

99999V999999

Units Invoiced

12

999999999V999

Adjusted Units (+/-)

13

9999999999V999

Labeler Disputed Units

12

999999999V999

Units Paid

12

999999999V999

Adjustment Code(s)

3

See Adjustment and Dispute Codes for CMS-304/304a

Dispute Code(s)

3

See Adjustment and Dispute Codes for CMS-304/304a

Rebate Amount Invoiced

9

9999999V99

Invoice Correction Amount (+/-)

10

99999999V99

Withheld Invoice Amount

9

9999999V99

Rebate Amount Paid

9

9999999V99



MEDICAID DRUG REBATE

RECONCILIATION OF STATE INVOICE (ROSI) CMS-304

ELECTRONIC FORMAT

RECORD 3

FIELD

SIZE

REMARKS

Record ID

1

Constant of “3”

Labeler Code

5

NDC 1

Total Units Invoiced

12

999999999V999

Total Adjusted Units (+/-)

13

9999999999V999

Total Labeler Disputed Units

12

999999999V999

Total Units Paid

12

999999999V999

Total Rebate Amount Invoiced

10

99999999V99

Total Invoice Correction Amt. (+/-)

11

999999999V99

Total Withheld Invoice Amount

10

99999999V99

Total Rebate Amount Paid

10

99999999V99

Plus Interest Payment

8

999999V99

Total Remittance

10

99999999V99























File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMEDICAID DRUG REBATE Appendix A
AuthorHCFA Software Control
File Modified0000-00-00
File Created2021-01-14

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