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Agenda
Reg Review
ICR
View Information Collection (IC)
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-R-153
FFS Medicaid Annual Report
FFS Medicaid DUR Survey FFY 2021_08.16.2021_Clean_508._Updated _11-29-21.pdf
Yes
Yes
Fillable Printable
Form
CMS-R-153
MCO Medicaid Annual Report
MCO Medicaid DUR Survey FFY 2021_8.16.2021 Clean_508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-R-153
State DUR Agency Contact Form
PRA - DUR State Contact Form_2020_Final_508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-R-153
Abbreviated MCO Report
Abbreviated MCO Medicaid DUR Survey FFY 2021_08.16.21_Clean_508.pdf
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:
51
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
51
0
0
0
0
51
Annual IC Time Burden (Hours)
3,264
0
0
0
0
3,264
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk: • FFS Annual Report
Crosswalk - FFS Annual Report 2021 Final_Updated_2.17.22.xlsx
02/18/2022
Crosswalk: Abbreviated MCO Report
Crosswalk - MCO Abbreviated Annual Report 2021 Final 2.17.21.xlsx
02/18/2022
Crosswalk: MCO Annual Report
Crosswalk - MCO Annual Report 2021 Final.xlsx
02/18/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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