Information Collection

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

IC 46422 under ICR 202102-0938-015 · OMB 0938-0676.

⚠️ Notice: This information collection may be referencing outdated material.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

2024-03-07 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-304a Prior Quarter Adjustment Statement (PQAS) (CMS-304a)	Form
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_07.2021_508.pdf	Instruction
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_07.2021_508.pdf	Instruction
Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf	Instruction
Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf	Instruction
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_07.2021_508.pdf	Instruction
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_07.2021_508.pdf	Instruction
CMS-304a Prior Quarter Adjustment Statement (PQAS) CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_07.2021_508.pdf	Form
CMS-304a Prior Quarter Adjustment Statement (PQAS) CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_07.2021_508.pdf	Form
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Crosswalk_07.2021_508.pdf CMS-304a - PQAS Crosswalk	IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Crosswalk_07.2021_508.pdf CMS-304a - PQAS Crosswalk	IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_Crosswalk_07.2021_508.pdf CMS-304a - Electronic Format Crosswalk	IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_Crosswalk_07.2021_508.pdf CMS-304a - Electronic Format Crosswalk	IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_Crosswalk_07.2021_508.pdf CMS-304a - Instructions Crosswalk	IC Document
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_Crosswalk_07.2021_508.pdf CMS-304a - Instructions Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

table that charts list of 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 Form-304a Prior Quarter Adjustment Statement (PQAS)_07.2021_508.pdf	Yes	Yes	Fillable Printable
Instruction			CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_07.2021_508.pdf	Yes	Yes	Fillable Printable
Instruction			Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf	Yes	No	Printable Only
Instruction			CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_07.2021_508.pdf	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 749

Number of Respondents for Small Entity: 60

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,996	44	2,952
Annual IC Time Burden (Hours)	83,888	1,232	82,656
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-304a - PQAS Crosswalk	CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Crosswalk_07.2021_508.pdf	02/23/2021
CMS-304a - Electronic Format Crosswalk	CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_Crosswalk_07.2021_508.pdf	02/23/2021
CMS-304a - Instructions Crosswalk	CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_Crosswalk_07.2021_508.pdf	02/23/2021

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