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

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

OMB: 0938-0676

IC ID: 46422

Documents and Forms
Document Name
Document Type
Form
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Information Collection (IC) Details

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Prior Quarter Adjustment Statement (PQAS) (CMS-304a)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

816 60
   
Private Sector Businesses or other for-profits
 
   85 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,264 0 0 268 0 2,996
Annual IC Time Burden (Hours) 91,392 0 0 7,504 0 83,888
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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