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

Documents and Forms

Document Name Document Type
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_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 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