Information Collection

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

IC 8242 under ICR 202112-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: â¢ 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.