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
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Information Collection (IC) Details

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Reconciliation of State Invoice (ROSI) (CMS-304)
 
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
Instruction CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf Yes No Fillable Printable
Form CMS-304 Reconciliation of State Invoice (ROSI) CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf Yes Yes Fillable Printable
Instruction CMS Form-304 Reconciliation of State Invoice (ROSI)_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

Health Health Care Services

 

571 41
   
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 2,284 0 0 188 0 2,096
Annual IC Time Burden (Hours) 159,880 0 0 13,160 0 146,720
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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