Information Collection

Quarterly Utilization Report (CMS-R-144)

IC 212418 under ICR 202404-0938-010 · OMB 0938-0582.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-144 Quarterly Utilization Report (CMS-R-144)	Form
CMS-R-144 State Invoice_Data Definitions_10.2021_Final.pdf	Instruction
CMS-R-144 State Invoice_Data Definitions_10.2021_Final.pdf	Instruction
Invoice Process Instructions_10.2021_Final.pdf	Instruction
Invoice Process Instructions_10.2021_Final.pdf	Instruction
CMS-R-144 State Invoice_Record Format_10.2021_Final.pdf	Instruction
CMS-R-144 State Invoice_Record Format_10.2021_Final.pdf	Instruction
CMS-R-144 Medicaid Drug Rebate Invoice CMS-R-144 State Invoice_10.2021_Final.pdf	Form
CMS-R-144 Medicaid Drug Rebate Invoice CMS-R-144 State Invoice_10.2021_Final.pdf	Form
CMS-R-144 State Invoice_Data Definitions_Crosswalk_10.2021.pdf Crosswalk: Data Definitions	IC Document
CMS-R-144 State Invoice_Data Definitions_Crosswalk_10.2021.pdf Crosswalk: Data Definitions	IC Document

IC Title:

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
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS-R-144 State Invoice_10.2021_Final.pdf	Yes	Yes	Fillable Printable
Instruction			CMS-R-144 State Invoice_Data Definitions_10.2021_Final.pdf	Yes	No	Printable Only
Instruction			Invoice Process Instructions_10.2021_Final.pdf	Yes	No	Printable Only
Instruction			CMS-R-144 State Invoice_Record Format_10.2021_Final.pdf	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
	Approved	Previously Approved
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	12,320	12,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Data Definitions	CMS-R-144 State Invoice_Data Definitions_Crosswalk_10.2021.pdf	02/17/2022

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