Reconciliation of State Invoice (ROSI) (CMS-304)

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

OMB: 0938-0676

IC ID: 8261

⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf Instruction
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf Instruction
CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_07.2021_508.pdf Instruction
CMS Form-304 Reconciliation of State Invoice (ROSI)_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-304 Reconciliation of State Invoice (ROSI) CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf Form
CMS-304 Reconciliation of State Invoice (ROSI) CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf Form
CMS Form-304 Reconciliation of State Invoice (ROSI)_Crosswalk_07.2021_508.pdf CMS-304 Crosswalk IC Document
CMS Form-304 Reconciliation of State Invoice (ROSI)_Crosswalk_07.2021_508.pdf CMS-304 Crosswalk IC Document
CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_Crosswalk_07.2021_508.pdf CMS-304 - Electronic Format Crosswalk IC Document
CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_Crosswalk_07.2021_508.pdf CMS-304 - Electronic Format Crosswalk IC Document
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_Crosswalk_07.2021_508.pdf CMS-304 - Instructions Crosswalk IC Document
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_Crosswalk_07.2021_508.pdf CMS-304 - Instructions Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reconciliation of State Invoice (ROSI) (CMS-304)	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
Instruction			CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf	Yes	No	Fillable Printable
Form	CMS-304	Reconciliation of State Invoice (ROSI)	CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf	Yes	Yes	Fillable Printable
Instruction			CMS Form-304 Reconciliation of State Invoice (ROSI)_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

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: 524	Number of Respondents for Small Entity: 41

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	2,096	28	2,068
Annual IC Time Burden (Hours)	146,720	1,960	144,760
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-304 Crosswalk	CMS Form-304 Reconciliation of State Invoice (ROSI)_Crosswalk_07.2021_508.pdf	02/23/2021
CMS-304 - Electronic Format Crosswalk	CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_Crosswalk_07.2021_508.pdf	02/23/2021
CMS-304 - Instructions Crosswalk	CMS Form-304 Reconciliation of State Invoice (ROSI)_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.