Information Collection

Medicaid Drug Ulilization Review (DUR) Annual Report (42 CFR 456.712 and 438.3)

IC 8242 under ICR 201809-0938-001 · OMB 0938-0659.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0659 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-153 Medicaid Drug Ulilization Review (DUR) Annual Report (42 CFR 456.712 and 438.3)	Form
CMS-R-153 FFS Medicaid Annual Report DUR FFY 2015 Final Medicaid DUR Report 1-28-16 508 v1.pdf	Form
CMS-R-153 MCO Medicaid Annual Report DUR - PRA - MCO MEDICAID ANNUAL REPORT FFY 2018 - 508 Compliant.pdf	Form
CMS-R-153 DUR Survey Tool DUR - PRA - MDP System DUR Survey Tool 2018.pptx	Form
DUR - PRA - Crosswalk FFY 2018_508 Compliant.xlsx Crosswalk	IC Document

IC Title:

Medicaid Drug Ulilization Review (DUR) Annual Report (42 CFR 456.712 and 438.3)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 456.712

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-153	FFS Medicaid Annual Report	DUR FFY 2015 Final Medicaid DUR Report 1-28-16 508 v1.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-153	MCO Medicaid Annual Report	DUR - PRA - MCO MEDICAID ANNUAL REPORT FFY 2018 - 508 Compliant.pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-153	DUR Survey Tool	DUR - PRA - MDP System DUR Survey Tool 2018.pptx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	51	0	51
Annual IC Time Burden (Hours)	3,264	1,632	1,632
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	DUR - PRA - Crosswalk FFY 2018_508 Compliant.xlsx	09/26/2018

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