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 FFS Medicaid DUR Survey FFY 2021_08.16.2021_Clean_508._Updated _11-29-21.pdf Form
CMS-R-153 FFS Medicaid Annual Report FFS Medicaid DUR Survey FFY 2021_08.16.2021_Clean_508._Updated _11-29-21.pdf Form
CMS-R-153 MCO Medicaid Annual Report MCO Medicaid DUR Survey FFY 2021_8.16.2021 Clean_508.pdf Form
CMS-R-153 MCO Medicaid Annual Report MCO Medicaid DUR Survey FFY 2021_8.16.2021 Clean_508.pdf Form
CMS-R-153 State DUR Agency Contact Form PRA - DUR State Contact Form_2020_Final_508.pdf Form
CMS-R-153 State DUR Agency Contact Form PRA - DUR State Contact Form_2020_Final_508.pdf Form
CMS-R-153 Abbreviated MCO Report Abbreviated MCO Medicaid DUR Survey FFY 2021_08.16.21_Clean_508.pdf Form
CMS-R-153 Abbreviated MCO Report Abbreviated MCO Medicaid DUR Survey FFY 2021_08.16.21_Clean_508.pdf Form
Crosswalk - FFS Annual Report 2021 Final_Updated_11-29-21.pdf Crosswalk: • FFS Annual Report IC Document
Crosswalk - FFS Annual Report 2021 Final_Updated_2.17.22.xlsx Crosswalk: • FFS Annual Report IC Document
Crosswalk - MCO Abbreviated Annual Report 2021 Final.pdf Crosswalk: Abbreviated MCO Report IC Document
Crosswalk - MCO Abbreviated Annual Report 2021 Final 2.17.21.xlsx Crosswalk: Abbreviated MCO Report IC Document
Crosswalk - MCO Annual Report 2021 Final.pdf Crosswalk: MCO Annual Report IC Document
Crosswalk - MCO Annual Report 2021 Final.xlsx Crosswalk: MCO Annual Report IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-153	FFS Medicaid Annual Report	FFS Medicaid DUR Survey FFY 2021_08.16.2021_Clean_508._Updated _11-29-21.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-153	MCO Medicaid Annual Report	MCO Medicaid DUR Survey FFY 2021_8.16.2021 Clean_508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-153	State DUR Agency Contact Form	PRA - DUR State Contact Form_2020_Final_508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-153	Abbreviated MCO Report	Abbreviated MCO Medicaid DUR Survey FFY 2021_08.16.21_Clean_508.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	3,264	3,264
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: • FFS Annual Report	Crosswalk - FFS Annual Report 2021 Final_Updated_2.17.22.xlsx	02/18/2022
Crosswalk: Abbreviated MCO Report	Crosswalk - MCO Abbreviated Annual Report 2021 Final 2.17.21.xlsx	02/18/2022
Crosswalk: MCO Annual Report	Crosswalk - MCO Annual Report 2021 Final.xlsx	02/18/2022

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

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

Medicaid Drug Utilization Review (DUR) Program (CMS-R-153)

OMB: 0938-0659

IC ID: 8242

View Information Collection (IC)