View Information Collection (IC)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS-R-144 with Disclosure Statement_2017.pdf		Yes	Yes	Fillable Printable
Instruction			CMS-R-144 Data Definitions_2017.pdf		Yes	No	Printable Only
Instruction			Invoice Process Instructions_Clean_05.08.17.docx		Yes	No	Printable Only
Instruction			CMS-R-144 Record Layout_2017.pdf		Yes	Yes	Printable Only

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: 56	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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	224	0	0	0	0	224
Annual IC Time Burden (Hours)	12,096	0	0	0	0	12,096
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - Invoice Process Instructions	Invoice Process Instructions_TC_05.08.17.docx	06/21/2017

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