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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
State Drug Rebate (Medicaid)
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-368
State Agency Contact Form
CMS Form 368.doc
Yes
Yes
Fillable Fileable
Form
CMS-R-144
Medicaid Drug Rebate Invoice
CMS R-144_2011.pdf
Yes
Yes
Fillable Fileable
Instruction
Invoice Instructions_Final_2011.doc
Yes
No
Printable Only
Instruction
ACA Record Layout_Final_2011.docx
Yes
No
Printable Only
Instruction
ACA Data Definitions_Final_2011.docx
Yes
No
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
20
0
0
0
204
Annual IC Time Burden (Hours)
12,101
2,712
0
0
0
9,389
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CMS-R-144 Crosswalk - State invoice Field Definitions
ACA Data Definitions_TC_2011.docx
07/20/2011
CMS-R-144 Crosswalk - State Invoice Record Format
ACA Record Layout_TC_2011.docx
07/20/2011
Crosswalk - Invoice Process
Invoice Instructions_TC_2011.doc
07/20/2011
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.