What is Medicaid Drug Rebate Dispute Resolution?
The Medicaid Drug Rebate Dispute Resolution Program (DRP) is for states and/or manufacturers that are unable to mutually resolve Medicaid Drug Rebate Program (MDRP) disputes, in which they may request assistance from CMS’s Medicaid DRP Team.
In order for a dispute to be considered an official dispute, the state/manufacturer need to have documented the disputed units on the official Reconciliation of State Invoice (ROSI) or Prior Quarter Adjustment Statement (PQAS) which must be filled out completely, including the assignment of the appropriate dispute code(s), and any required documentation for the dispute code(s). Please note that an excel spreadsheet without appropriate context is not considered official documentation.
For current versions of MDRP File Formats/Data Definitions, please refer to: https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/medicaid-drug-rebate-program-mdrp-file-formats-data-definitions-and-medicaid-drug-programs-mdp-email-communications/index.html.
All disputes must be resolved on a unit basis only, and not on any other factor (e.g., monetary amounts, percentages, etc.). Additionally, non-payment of rebates are not disputes. CMS considers any unpaid rebates billed to manufacturers and not paid timely, without the required dispute documentation, as non-payment. Non-payment issues are addressed in Manufacturer Release No.105, and State Release No.181, and inquiries pertaining to non-payment should be sent to MDROperations@cms.hhs.gov (please include “Non-Payment” in the subject line).
Most states and manufacturers prefer to engage in the dispute resolution process; however, per Section V of the National Drug Rebate Agreement (NDRA), in accordance with 42 CFR §447.253(e), a state hearing option is available to both states and manufacturers when they have reached an impasse through the normal dispute resolution process, or when one of the parties is not being responsive to another’s efforts to engage in dispute resolution. Please note that either party may opt to use the state hearing process at any time; however, both parties must agree to engage in order to use the DRP process. The state hearing option is addressed in Manufacturer Release No.105 and State Release No.181.
DRP Resources
- DRP Hot Topics/Best Practices
- ROSI (304)/PQAS (304a) Templates
- Adjustment/Dispute Codes
- ND Medicaid Unit Conversion File (May 2, 2024)
- This data is provided "as is", and the Centers for Medicare and Medicaid Services (CMS) assumes no responsibility for errors or omissions. The User assumes entire risk associated with its use of this data. The CMS shall not be held liable for any use or misuse of this data described and/or contained herein. The User bears all responsibility in determining whether this data is fit for the User's intended use.
- Status of Prescription Numbers under the Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule
- Federal Policy Guidance on HCPCS J-Codes Billing
- Suggestions for Resolving Aged Disputes
- Manufacturer Release No. 105
- State Release No. 181
- State Release No. 177
- Manufacturer Release No. 100
- National Drug Rebate Agreement (NDRA)
- 42 CFR §447.253(e)
- Medicaid Pharmacy Email Resources
Contact Information: If you have any questions, please contact the Dispute Resolution Program (DRP) Team at DRP@cms.hhs.gov
Disclaimer: Please note that the information provided on this web page does not bind or obligate the Centers for Medicare and Medicaid Services (CMS). The statements included on this web page are intended to provide information on the Medicaid Drug Rebate Dispute Resolution Program (DRP) and do not in any way revise or modify the requirements set forth in Section 1927 of the Act, the national drug rebate agreement (NDRA), subsequent program releases, or regulations.
Page last updated on May 2, 2024