Information Collection

Quarterly Utilization Report (CMS-R-144)

IC 212418 under ICR 202006-0938-018 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-R-144 State Invoice_Data Definitions_12.2019_Final.docx	Yes	No	Printable Only
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS-R-144 State Invoice_12.2019_Final.pdf	Yes	Yes	Fillable Printable
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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	280	56	224
Annual IC Time Burden (Hours)	12,488	392	12,096
Annual IC Cost Burden (Dollars)	0	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.