Information Collection

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

IC 8242 under ICR 202409-0938-002 · OMB 0938-0659.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0659 can be found here:

2025-01-15 - Revision of a currently approved collection

Documents and Forms

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 Annual Surveys FFS Annual Surveys CLEAN (2024 version 1).docx Form
CMS-R-153 FFS Annual Surveys FFS Annual Surveys CLEAN (2024 version 1).docx Form
CMS-R-153 MCO Annual Surveys MCO Annual Surveys CLEAN (2024 version 1).docx Form
CMS-R-153 MCO Annual Surveys MCO Annual Surveys CLEAN (2024 version 1).docx Form
CMS-R-153 State DUR Agency Contact Form DUR State Contact Form_2025 Fillable.pdf Form
CMS-R-153 State DUR Agency Contact Form DUR State Contact Form_2025 Fillable.pdf Form
CMS-R-153 Abbreviated MCO Surveys Abbreviated MCO Surveys CLEAN (2024 version 1).docx Form
CMS-R-153 Abbreviated MCO Surveys Abbreviated MCO Surveys CLEAN (2024 version 1).docx Form
FFS Annual Surveys CROSSWALK (2024 version 1).pdf CROSSWALK: FFS Annual Surveys IC Document
FFS Annual Surveys CROSSWALK (2024 version 1).pdf CROSSWALK: FFS Annual Surveys IC Document
FFS Annual Surveys REDLINE (2024 version 1).pdf REDLINE: FFS Annual Surveys IC Document
FFS Annual Surveys REDLINE (2024 version 1).pdf REDLINE: FFS Annual Surveys IC Document
MCO Annual Surveys CROSSWALK (2024 version 1).pdf CROSSWALK: MCO Annual Surveys IC Document
MCO Annual Surveys CROSSWALK (2024 version 1).pdf CROSSWALK: MCO Annual Surveys IC Document
MCO Annual Surveys REDLINE (2024 version 1).pdf REDLINE: MCO Annual Surveys IC Document
MCO Annual Surveys REDLINE (2024 version 1).pdf REDLINE: MCO Annual Surveys IC Document
Abbreviated MCO Surveys CROSSWALK (2024 version 1).pdf CROSSWALK: Abbreviated MCO Surveys IC Document
Abbreviated MCO Surveys CROSSWALK (2024 version 1).pdf CROSSWALK: Abbreviated MCO Surveys IC Document
Abbreviated MCO Surveys REDLINE (2024 version 1.pdf REDLINE: Abbreviated MCO Surveys IC Document
Abbreviated MCO Surveys REDLINE (2024 version 1.pdf REDLINE: Abbreviated MCO Surveys 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 Annual Surveys	FFS Annual Surveys CLEAN (2024 version 1).docx	Yes	Yes	Fillable Printable
Form	CMS-R-153	MCO Annual Surveys	MCO Annual Surveys CLEAN (2024 version 1).docx	Yes	Yes	Fillable Fileable
Form	CMS-R-153	State DUR Agency Contact Form	DUR State Contact Form_2025 Fillable.pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-153	Abbreviated MCO Surveys	Abbreviated MCO Surveys CLEAN (2024 version 1).docx	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: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52	1	51
Annual IC Time Burden (Hours)	3,380	116	3,264
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CROSSWALK: FFS Annual Surveys	FFS Annual Surveys CROSSWALK (2024 version 1).pdf	09/04/2024
REDLINE: FFS Annual Surveys	FFS Annual Surveys REDLINE (2024 version 1).pdf	09/04/2024
CROSSWALK: MCO Annual Surveys	MCO Annual Surveys CROSSWALK (2024 version 1).pdf	09/04/2024
REDLINE: MCO Annual Surveys	MCO Annual Surveys REDLINE (2024 version 1).pdf	09/04/2024
CROSSWALK: Abbreviated MCO Surveys	Abbreviated MCO Surveys CROSSWALK (2024 version 1).pdf	09/04/2024
REDLINE: Abbreviated MCO Surveys	Abbreviated MCO Surveys REDLINE (2024 version 1.pdf	09/04/2024

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