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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0676 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-304a Prior Quarter Adjustment Statement (PQAS) (CMS-304A) Form
PQAS Electronic Format for CMS-304a_2019_Final.docx Instruction
Adjustment and Dispute Codes for CMS-304_304a_2019_Final.docx Instruction
Instructions for CMS-304a PQAS_2019_Final.docx Instruction
CMS-304a Prior Quarter Adjustment Statement (PQAS) CMS-304a Prior Quarter Adjustment Statement (PQAS)_2019_Final.docx Form
CMS-304a Prior Quarter Adjustment Statement (PQAS)_2019_TC.docx Track Change - Prior Quarter Adjustment Statement (PQAS) IC Document
PQAS Electronic Format for CMS-304a_2019_TC.docx Track Change - Electronic Format IC Document
Adjustment and Dispute Codes for CMS-304_304a_Crosswalk_2019.xlsx Crosswalk - Adjustment and Dispute Codes IC Document
Adjustment and Dispute Codes for CMS-304_304a_2019_TC.docx Track Change - Adjustment and Dispute Codes IC Document
Instructions for CMS-304a_Crosswalk_2019.xlsx Crosswalk - Instructions IC Document
Instructions for CMS-304a PQAS_2019_TC.docx Track Change - Instructions IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Crosswalk_2019.xlsx Crosswalk - Prior Quarter Adjustment Statement (PQAS) IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Forma....xlsx Crosswalk - Electronic Format IC Document

Information Collection (IC) Details

IC Title:	Prior Quarter Adjustment Statement (PQAS) (CMS-304A)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-304a	Prior Quarter Adjustment Statement (PQAS)	CMS-304a Prior Quarter Adjustment Statement (PQAS)_2019_Final.docx	Yes	Yes	Fillable Printable
Instruction			PQAS Electronic Format for CMS-304a_2019_Final.docx	Yes	Yes	Fillable Printable
Instruction			Adjustment and Dispute Codes for CMS-304_304a_2019_Final.docx	Yes	No	Printable Only
Instruction			Instructions for CMS-304a PQAS_2019_Final.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 738	Number of Respondents for Small Entity: 60

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,952	324	2,628
Annual IC Time Burden (Hours)	82,656	9,072	73,584
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change - Prior Quarter Adjustment Statement (PQAS)	CMS-304a Prior Quarter Adjustment Statement (PQAS)_2019_TC.docx	03/17/2020
Track Change - Electronic Format	PQAS Electronic Format for CMS-304a_2019_TC.docx	03/17/2020
Crosswalk - Adjustment and Dispute Codes	Adjustment and Dispute Codes for CMS-304_304a_Crosswalk_2019.xlsx	03/31/2020
Track Change - Adjustment and Dispute Codes	Adjustment and Dispute Codes for CMS-304_304a_2019_TC.docx	03/17/2020
Crosswalk - Instructions	Instructions for CMS-304a_Crosswalk_2019.xlsx	03/17/2020
Track Change - Instructions	Instructions for CMS-304a PQAS_2019_TC.docx	03/17/2020
Crosswalk - Prior Quarter Adjustment Statement (PQAS)	CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Crosswalk_2019.xlsx	03/31/2020
Crosswalk - Electronic Format	CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Forma....xlsx	03/31/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.