Information Collection

Quarterly Utilization Report (CMS-R-144)

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

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_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

Information Collection (IC) Details

View Information Collection (IC)

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_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 %

	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

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.