Information Collection

Quarterly Utilization Report (CMS-R-144)

IC 212418 under ICR 201407-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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-R-144 Quarterly Utilization Report (CMS-R-144)	Form
Data Definitions_2014.pdf	Instruction
Invoice Instructions_2014.pdf	Instruction
Record Layout_2014.pdf	Instruction
CMS-R-144 Disclosure Statement_2014.doc	Other-PRA Disclosure Statement
CMS-R-144 Medicaid Drug Rebate Invoice CMS R-144_2014.pdf	Form

IC Title:

Quarterly Utilization Report (CMS-R-144)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-R-144	Medicaid Drug Rebate Invoice	CMS R-144_2014.pdf	Yes	Yes	Fillable Printable
Instruction			Data Definitions_2014.pdf	Yes	No	Printable Only
Instruction			Invoice Instructions_2014.pdf	Yes	No	Printable Only
Instruction			Record Layout_2014.pdf	Yes	Yes	Printable Only
Other-PRA Disclosure Statement			CMS-R-144 Disclosure Statement_2014.doc	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
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	12,096	12,096
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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