State Drug Rebate (Medicaid)

State Drug Rebate (Medicaid) (CMS-368 and R-144)

OMB: 0938-0582

IC ID: 8197

Information Collection (IC) Details

View Information Collection (IC)

State Drug Rebate (Medicaid)
 
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
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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  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 224 20 0 0 0 204
Annual IC Time Burden (Hours) 12,101 2,712 0 0 0 9,389
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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