Track Change - Electronic Format

PQAS Electronic Format for CMS-304a_2019_TC.docx

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

Track Change - Electronic Format

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MEDICAID DRUG REBATE

PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS) CMS-304a

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”

Original Unit Rebate Amount

11

99999V999999

Current Unit Rebate Amount

11

99999V999999

Original Units Invoiced

12

999999999V999

Current Units to Date

12

999999999V999

Prior Units Paid

12

999999999V999

Current Units Paid to Date

12

999999999V999

Prior Units Disputed

12

999999999V999

Current Units Disputed to Date

12

999999999V999

Original Amount Invoiced

9

9999999V99

Revised Invoice Amount

9

9999999V99

Prior Amount Paid

9

9999999V99

Current Amount Paid to Date

9

9999999V99

Amount Paid This Transaction

9

9999999V99

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









MEDICAID DRUG REBATE

PRIOR QUARTER ADJUSTMENT STATEMENT CMS-304a

ELECTRONIC FORMAT

RECORD 3

FIELD

SIZE

REMARKS

Record ID

1

Constant of “3”

Labeler Code

5

NDC 1

Total Original Units Invoiced

12

Total for all NDCs 999999999V999

Total Current Units to Date

12

Total for all NDCs 999999999V999

Total Prior Units Paid

12

Total for all NDCs 999999999V999

Total Current Units Paid to Date

12

Total for all NDCs 999999999V999

Total Prior Units Disputed

12

Total for all NDCs 999999999V999

Total Current Units Disputed to Date

12

Total for all NDCs 999999999V999

Total Original Amount Invoiced

10

Total for all NDCs 99999999V99

Total Revised Invoice Amount

10

Total for all NDCs 99999999V99

Total Prior Amount Paid

10

Total for all NDCs 99999999V99

Total Current Amount Paid to Date

10

Total for all NDCs 99999999V99

Total Amount Paid This Transaction

10

Total for all NDCs 99999999V99

Plus Interest Payment

8

Total for all NDCs 999999V99

Total Remittance

10

Total for all NDCs 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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