Information Collection

State Drug Rebate (Medicaid)

IC 8197 under ICR 201107-0938-012 · OMB 0938-0582.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0582 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-368 State Drug Rebate (Medicaid)	Form
Invoice Instructions_Final_2011.doc	Instruction
ACA Record Layout_Final_2011.docx	Instruction
ACA Data Definitions_Final_2011.docx	Instruction
CMS-368 State Agency Contact Form CMS Form 368.doc	Form
CMS-R-144 Medicaid Drug Rebate Invoice CMS R-144_2011.pdf	Form
ACA Data Definitions_TC_2011.docx CMS-R-144 Crosswalk - State invoice Field Definitions	IC Document
ACA Record Layout_TC_2011.docx CMS-R-144 Crosswalk - State Invoice Record Format	IC Document
Invoice Instructions_TC_2011.doc Crosswalk - Invoice Process	IC Document

IC Title:

State Drug Rebate (Medicaid)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-368	State Agency Contact Form	CMS Form 368.doc	Yes	Yes	Fillable Fileable
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS R-144_2011.pdf	Yes	Yes	Fillable Fileable
Instruction			Invoice Instructions_Final_2011.doc	Yes	No	Printable Only
Instruction			ACA Record Layout_Final_2011.docx	Yes	No	Printable Only
Instruction			ACA Data Definitions_Final_2011.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	224	20	204
Annual IC Time Burden (Hours)	12,101	2,712	9,389
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-R-144 Crosswalk - State invoice Field Definitions	ACA Data Definitions_TC_2011.docx	07/20/2011
CMS-R-144 Crosswalk - State Invoice Record Format	ACA Record Layout_TC_2011.docx	07/20/2011
Crosswalk - Invoice Process	Invoice Instructions_TC_2011.doc	07/20/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.