← Glossary · CMS & regulatory
At-risk determination
A sponsor's decision, under its drug management program, that an enrollee is or is not at risk for prescription drug abuse.
At-risk determinations are made under 42 CFR 423.153(f) and reported in Universe Table 7 (AR) with the result At-Risk or Not At-Risk. Appeals of them go in Table 4 (RD), and IRE/ALJ/MAC reversals in Table 5 (EFF_D).
Source: CDAG protocol, Universe Table 7 guidance, p. 56.