CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_07.2021_508

MEDICAID DRUG REBATE PROGRAM

PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS)
Form CMS-304a
ELECTRONIC FILE FORMAT
Effective: July 1, 2021

RECORD 1 - PQAS
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 “P1” for PQAS 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 - PQAS
Ordinal
Position
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Field Name (.TXT)
Header Row (.CSV)
Record ID
Labeler Code
Product Code/Package
FDA Product Name
FFS/MCO Record ID
Original Unit Rebate Amount
Current Unit Rebate Amount
Original Units Invoiced
Current Units to Date
Prior Units Paid
Current Units Paid to Date
Prior Units Disputed
Current Units Disputed to Date
Original Amount Invoiced
Revised Invoice Amount
Prior Amount Paid
Current Amount Paid to Date
Amount Paid This Transaction

Size

Position

Remarks

2
5
6
10
4
15
15
16
16
16
16
16
16
16
16
16
16
16

1-2
3-7
8 - 13
14 - 23
24 - 27
28 - 42
43 - 57
58 - 73
74 - 89
90 - 105
106 - 121
122 - 137
138 - 153
154 - 169
170 - 185
186 - 201
202 - 217
218 - 233

Constant of “P2” for PQAS 2
NDC 1
NDC 2 and 3
First 10 Positions of Product Name
Constant of “FFSU” or “MCOU”
99999999.999999
99999999.999999
999999999999.999
999999999999.999
999999999999.999
999999999999.999
999999999999.999
999999999999.999
9999999999999.99
9999999999999.99
9999999999999.99
9999999999999.99
9999999999999.99
See Adjustment/Dispute Codes for CMS304/304a
See Adjustment/Dispute Codes for CMS304/304a

19

Adjustment Code(s)

3

234 - 236

20

Dispute Code(s)

3

237 - 239

MEDICAID DRUG REBATE PROGRAM

PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS)
Form CMS-304a
ELECTRONIC FILE FORMAT
Effective: July 1, 2021

RECORD 3 - PQAS
Ordinal
Position
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Field Name (.TXT)
Header Row (.CSV)
Record ID
Labeler Code
Total Original Units Invoiced
Total Current Units to Date
Total Prior Units Paid
Total Current Units Paid to Date
Total Prior Units Disputed
Total Current Units Disputed to Date
Total Original Amount Invoiced
Total Revised Invoice Amount
Total Prior Amount Paid
Total Current Amount Paid to Date
Total Amount Paid This Transaction
Plus Interest Payment
Total Remittance

Size

Position

Remarks

2
5
16
16
16
16
16
16
16
16
16
16
16
16
16

1-2
3-7
8 - 22
23 - 37
38 - 52
53 - 67
68 - 82
83 - 97
98 - 113
114 - 129
130 - 145
146 - 161
162 - 177
178 - 193
194 - 209

Constant of “P3” for PQAS 3
NDC 1
Total for all NDCs 999999999999.999
Total for all NDCs 999999999999.999
Total for all NDCs 999999999999.999
Total for all NDCs 999999999999.999
Total for all NDCs 999999999999.999
Total for all NDCs 999999999999.999
Total for all NDCs 9999999999999.99
Total for all NDCs 9999999999999.99
Total for all NDCs 9999999999999.99
Total for all NDCs 9999999999999.99
Total for all NDCs 9999999999999.99
Total for all NDCs 9999999999999.99
Total for all NDCs 9999999999999.99