OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0938-0676 · HHS/CMS.

OMB 0938-0676

Section 1927 of the Social Security Act requires drug manufacturers to enter into and have in effect a rebate agreement with CMS in order for States to receive funding for drugs dispensed to Medicaid recipients. Drug manufacturers must explain to States any rebate payment adjustments for the current quarter, and any prior quarters. The information is used to reconcile drug rebate payments made by manufacturers with the State invoices of rebates due.

The latest form for Reconciliation of State Invoice (ROSI) (CMS-304) and Prior Quarter Adjustment Statement (PQRS) (CMS-304a) expires 2027-07-31 and is listed under ICR 202403-0938-004.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-304a Prior Quarter Adjustment Statement (PQAS) (CMS-304a)Form
CMS-304_304a - Supporting Statement A (2024 version 6).docxSupporting Statement A
Reconciliation of State Invoice (ROSI) (CMS-304) Instruction
Prior Quarter Adjustment Statement (PQAS) (CMS-304a) Form
CMS-304 and CMS-304a – One-Time System Updates Information collection

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202403-0938-004 Revision of a currently approved collection 2024-03-07 Approved with change
202102-0938-015 Revision of a currently approved collection 2021-02-26 Approved without change
202003-0938-011 Revision of a currently approved collection 2020-03-31 Approved without change
201704-0938-010 Extension without change of a currently approved collection 2017-04-28 Approved without change
201407-0938-009 Extension without change of a currently approved collection 2014-07-22 Approved without change
201107-0938-007 Revision of a currently approved collection 2011-07-20 Approved without change
201001-0938-009 Extension without change of a currently approved collection 2010-01-27 Approved with change
200612-0938-003 Extension without change of a currently approved collection 2006-12-13 Approved without change
200402-0938-002 Revision of a currently approved collection 2004-02-05 Approved with change
200101-0938-008 Extension without change of a currently approved collection 2001-01-30 Approved without change
199909-0938-010 No material or nonsubstantive change to a currently approved collection 1999-09-30 Approved without change
199712-0938-007 Extension without change of a currently approved collection 1997-12-24 Approved without change
199701-0938-007 No material or nonsubstantive change to a currently approved collection 1997-01-24 Approved without change
199701-0938-006 No material or nonsubstantive change to a currently approved collection 1997-01-17 Approved without change
199603-0938-003 Revision of a currently approved collection 1996-03-19 Approved without change
199503-0938-004 New collection (Request for a new OMB Control Number) 1995-03-10 Approved without change

OMB Details

Reconciliation of State Invoice (ROSI) (CMS-304)

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form CMS-304Reconciliation of State Invoice (ROSI)Fillable PrintableForm

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.