Quarterly Utilization Report (CMS-R-144)

Medicaid Drug Rebate Program (MDRP): Quarterly State Invoice (CMS-R-144) and State Agency Contact Form (CMS-368)

⚠️ Notice: This information collection may be referencing outdated material.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
CMS-R-144 State Invoice_Data Definitions_12.2019_Final.docx Instruction
Invoice Process Instructions_12.2019_Final.docx Instruction
CMS-R-144 State Invoice_Record Format_12.2019_Final.docx Instruction
CMS-R-144 Medicaid Drug Rebate Invoice CMS-R-144 State Invoice_12.2019_Final.pdf Form
CMS-R-144 State Invoice_12.2019_TC.pdf State Invoice: Track Changes IC Document
CMS-R-144 State Invoice_Crosswalk_12.2019.pdf State Invoice: Crosswalk IC Document
CMS-R-144 State Invoice_Record Format_12.2019_TC.docx Record Format: Track Changes IC Document
CMS-R-144 State Invoice_Record Format_Crosswalk_12.2019.xlsx Record Format: Crosswalk IC Document
CMS-R-144 State Invoice_Data Definitions_12.2019_TC.docx Data Definitions: Track Changes IC Document
CMS-R-144 State Invoice_Data Definitions_Crosswalk_12.2019.xlsx Data Definitions: Crosswalk 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
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS-R-144 State Invoice_12.2019_Final.pdf	Yes	Yes	Fillable Printable
Instruction			CMS-R-144 State Invoice_Data Definitions_12.2019_Final.docx	Yes	No	Printable Only
Instruction			Invoice Process Instructions_12.2019_Final.docx	Yes	No	Printable Only
Instruction			CMS-R-144 State Invoice_Record Format_12.2019_Final.docx	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
State Invoice: Track Changes	CMS-R-144 State Invoice_12.2019_TC.pdf	04/09/2020
State Invoice: Crosswalk	CMS-R-144 State Invoice_Crosswalk_12.2019.pdf	04/09/2020
Record Format: Track Changes	CMS-R-144 State Invoice_Record Format_12.2019_TC.docx	04/09/2020
Record Format: Crosswalk	CMS-R-144 State Invoice_Record Format_Crosswalk_12.2019.xlsx	04/09/2020
Data Definitions: Track Changes	CMS-R-144 State Invoice_Data Definitions_12.2019_TC.docx	04/09/2020
Data Definitions: Crosswalk	CMS-R-144 State Invoice_Data Definitions_Crosswalk_12.2019.xlsx	04/09/2020

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