Adjustment and Dispute Codes for CMS-304_304a_07.2021_508

Adjustment and/or Dispute Codes for ROSI (Form CMS-304) and/or PQAS (Form CMS-304a)
A. Unit Rebate Amount (URA) has been revised by labeler and reported to CMS, as required.
B. Labeler has calculated URA and/or rebate where none (a zero URA) was reported by state.
C. Units invoiced adjusted through mutual agreement between labeler/state. Adjustments to be reflected to labeler and in
utilization reporting to CMS.
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.
E. State is invoicing a decimal value for whole number value (UPPS) reported by labeler.
F. *Package size discrepancy (e.g., could include correction to package size by labeler).
G. *Transferred NDC to another labeler code or company. (Labeler code is ultimately responsible for rebate payment.)
H. Utilization change from the state.
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.
J. No state reimbursement reflected on claims level detail.
K. *J-Code to NDC crosswalk requires validation data (e.g., crosswalk to products with multiple NDCs and/or package
sizes).
L. Generic Substitution.
M. Duplicate claim.
N. *Discontinued/terminated NDC for which the shelf life expired more than one year from the dispense date.
(Documentation should support dispensed date.)
O. Invalid/miscoded NDC.
P. *State units invoiced exceed unit sales. (Documentation should include supporting methodology and data source.)
Q. Utilization/quantity is inconsistent with the number of prescriptions.
R. *Utilization/quantity is inconsistent with pharmacy reimbursement levels, including Third Party Payments. (This
dispute code should be used in conjunction with another code or other supporting documentation.)
S. *Utilization/quantity is inconsistent with state historical trends or current state program information. (Documentation
should include trend/program information.)
T. Utilization/quantity is inconsistent with lowest dispensable package size.
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.).
V. *No record of sales directly to state or state history of purchase from out-of-state provider (e.g., border pharmacies,
mail order pharmacies, etc.).
W. Closed out. All disputes resolved.
X. *PHS entity not extracted from state data. (Documentation should include PHS provider number.)
*Supporting Documentation REQUIRED. Note: Some adjustment/dispute codes are specifically noted to require supporting documentation; however,
supporting documentation can always be submitted, even for those instances where it is not specifically mentioned in this document.