Crosswalk - Adjustment and Dispute Codes

Adjustment and Dispute Codes for CMS-304_304a_Crosswalk_2019.xlsx

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

Crosswalk - Adjustment and Dispute Codes

OMB: 0938-0676

Document [xlsx]
Download: xlsx | pdf
2017 (old version) 2019 (new version) Type of Change Reason for Change Burden Change
Header - Appendix C
N/A Deletion The reference to "Appendix C" is no longer applicable, so we have removed it. N/A
A. Unit rebate amount (URA) has been revised by labeler and reported to CMS, as required. A. Unit Rebate Amount (URA) has been revised by labeler and reported to CMS, as required. Rev To align verbiage with PRA packages 0938-0582 and 0938-0578 N/A
D. Unit Type and/or Units Per Package Size (UPPS) reported on state invoice is different than unit of measure (UOM) reported to CMS by labeler for NDC. Labeler and state to follow up to discuss the need for conversions prior to rebate invoice billing or labeler change in reported UOM. D. Unit Type (UT) and/or Units Per Package Size (UPPS) reported on state invoice is different than unit of measure (UOM) reported to CMS by labeler for NDC. Labeler and state to follow up to discuss the need for conversions prior to rebate invoice billing or labeler change in reported UOM. Rev To align verbiage with PRA packages 0938-0582 and 0938-0578 N/A
I. RPU amount adjusted through correspondence between labeler/state. USE THIS CODE ONLY when the state has reported a RPU not based on the CMS file and code A is not applicable. I. URA amount adjusted through correspondence between labeler/state. USE THIS CODE ONLY when the state has reported a URA not based on the CMS file and code A is not applicable. Rev To align verbiage with PRA packages 0938-0582 and 0938-0578 N/A
U. *Product not rebate eligible (e.g., product was not reported to CMS because the product is not a covered outpatient drug, product is for a non-Medicaid state-only program, an HMO non-Fee-For-Service program, etc.…). U. *Product not rebate eligible (e.g., product was not reported to CMS because the product is not a covered outpatient drug, product is for a non-Medicaid state-only program, an HMO non-Fee-For-Service program, etc.). Rev. To correct a punctuation error N/A



































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