CMS-304 Reconciliation of State Invoice (ROSI)

PAGE_____Of______
MEDICAID DRUG REBATE PROGRAM

RECONCILIATION OF STATE INVOICE (ROSI)

LABELER NAME: ______________________________________

LABLER CONTACT: _______________________________________

STATE: _______________________________________

LABELER CODE: _______________________________________

PHONE: __________________________________________________

INVOICE NO. __________________________________

PERIOD COVERED: __________________________________

EMAIL: ____________________________________________________

DATE: ________________________________________

A

B

PRODUCT/
PACKAGE
CODE

PRODUCT
NAME

C

D

FFS/MCO UNIT REBATE
RECORD ID
AMOUNT

E

ADJUSTED
UNIT
REBATE
AMOUNT

F

G

H

I

J

K

L

M

N

O

UNITS
INVOICED

ADJUSTED
UNITS
+ or -

LABELER
DISPUTED
UNITS

UNITS
PAID

ADJM
CODE

DISP
CODE

REBATE
AMOUNT
INVOICED

INVOICE
CORRECTION
AMOUNT

WITHELD
INVOICE
AMOUNT

REBATE
AMOUNT
PAID

TOTALS

CMS-304 (Exp. 06/30/2023
OMB No. 0938-0676

Plus Interest Payment
===========

TOTAL REMITTANCE
Form CMS-304 (ROSI: Reconciliation of State Invoice) is used by manufacturers to respond to the state’s rebate invoice for current quarter utilization. The use of Form CMS-304 by manufacturers is considered mandatory under the authority of
Section 1927 of the Social Security Act and the National Drug Rebate Agreement. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid control number for this information collection is 0938-0676. The time
required to complete this information collection is estimated to average 70 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland, 21244-1850.