Quarterly Utilization Report (CMS-R-144)

Medicaid Drug Rebate Program Forms (CMS-368 and CMS-R-144)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.