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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-R-144 Data Definitions_2017.pdf Instruction
Invoice Process Instructions_Clean_05.08.17.docx Instruction
CMS-R-144 Record Layout_2017.pdf Instruction
CMS-R-144 Medicaid Drug Rebate Invoice CMS-R-144 with Disclosure Statement_2017.pdf Form
Invoice Process Instructions_TC_05.08.17.docx Crosswalk - Invoice Process Instructions IC Document

Information Collection (IC) Details

IC Title:	Quarterly Utilization Report (CMS-R-144)	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-R-144 Data Definitions_2017.pdf	Yes	No	Printable Only
Instruction			Invoice Process Instructions_Clean_05.08.17.docx	Yes	No	Printable Only
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS-R-144 with Disclosure Statement_2017.pdf	Yes	Yes	Fillable Printable
Instruction			CMS-R-144 Record Layout_2017.pdf	Yes	Yes	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	Previously Approved
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
Crosswalk - Invoice Process Instructions	Invoice Process Instructions_TC_05.08.17.docx	06/21/2017

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