CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_07.2021_508

MEDICAID DRUG REBATE PROGRAM

RECONCILIATION OF STATE INVOICE (ROSI)
Form CMS-304
ELECTRONIC FILE FORMAT
Effective: July 1, 2021

RECORD 1 - ROSI
Ordinal
Position
1
2
3
4
5
6
7
8
9
10

Field Name (.TXT)
Header Row (.CSV)
Record ID
Labeler Name
Labeler Code
Period Covered
Labeler Contact
Phone
Email
State Code
Invoice Number
Date

Size

Position

Remarks

2
25
5
5
20
14
50
2
10
8

1-2
3 - 27
28 - 32
33 - 37
38 - 57
58 - 71
72 - 121
122 - 123
124 - 133
134 - 141

Constant of “R1” for ROSI 1
First 25 Positions of Company Name
NDC 1
QYYYY
Labeler’s Contact Person
Area Code/Phone No./Ext. of Invoice Contact
Labeler’s Invoice Contact Email Address
Two Position Postal Abbreviation
Corresponds to State Invoice Number
Date Report was Created

RECORD 2 - ROSI
Ordinal
Position
1
2
3
4
5
6
7
8
9
10
11

Field Name (.TXT)
Header Row (.CSV)
Record ID
Labeler Code
Product Code/Package
FDA Product Name
FFS/MCO Record ID
Unit Rebate Amount
Adjusted Unit Rebate Amount
Units Invoiced
Adjusted Units (+/-)
Labeler Disputed Units
Units Paid

Size

Position

2
5
6
10
4
15
15
16
17
16
16

1-2
3-7
8 - 13
14 - 23
24 - 27
28 - 42
43 - 57
58 - 73
74 - 90
91 - 106
107 - 122

12

Adjustment Code(s)

3

123 - 125

13

Dispute Code(s)

3

126 - 128

14
15
16
17

Rebate Amount Invoiced
Invoice Correction Amount (+/-)
Withheld Invoice Amount
Rebate Amount Paid

16
17
16
16

129 - 144
145 - 161
162 - 177
178 - 193

Remarks
Constant of “R2” for ROSI 2
NDC 1
NDC 2 and 3
First 10 Positions of Product Name
Constant of “FFSU” or “MCOU”
99999999.999999
99999999.999999
999999999999.999
9999999999999.999
999999999999.999
999999999999.999
See Adjustment/Dispute Codes for CMS304/304a
See Adjustment/Dispute Codes for CMS304/304a
9999999999999.99
99999999999999.99
9999999999999.99
9999999999999.99

MEDICAID DRUG REBATE PROGRAM

RECONCILIATION OF STATE INVOICE (ROSI)
Form CMS-304
ELECTRONIC FILE FORMAT
Effective: July 1, 2021

RECORD 3 – ROSI
Ordinal
Position
1
2
3
4
5
6
7
8
9
10
11
12

Field Name (.TXT)
Header Row (.CSV)
Record ID
Labeler Code
Total Units Invoiced
Total Adjusted Units (+/-)
Total Labeler Disputed Units
Total Units Paid
Total Rebate Amount Invoiced
Total Invoice Correction Amt. (+/-)
Total Withheld Invoice Amount
Total Rebate Amount Paid
Plus Interest Payment
Total Remittance

Size

Position

Remarks

2
5
16
17
16
16
16
17
16
16
16
16

1-2
3-7
8 - 23
24 - 40
41 - 56
57 - 72
73 - 88
89 - 105
106 - 121
122 - 137
138 - 153
154 - 169

Constant of “R3” for ROSI 3
NDC 1
999999999999.999
9999999999999.999
999999999999.999
999999999999.999
9999999999999.99
99999999999999.99
9999999999999.99
9999999999999.99
9999999999999.99
9999999999999.99