Track Change - Electronic Format

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