The Medicare prior authorization pilot program many practices are asking about is the Wasteful and Inappropriate Service Reduction (WISeR) Model. It is an active CMS Innovation Center model that began in 2026 and tests technology-supported prior authorization and pre-payment medical review for selected services in Original Medicare.
WISeR does not apply nationwide, does not apply to every Medicare service, and does not apply to Medicare Advantage. For affected providers and suppliers, however, it creates a new operational choice: request a coverage determination before the service or furnish the service and face pre-payment medical review before the claim is paid.
This guide is current as of July 19, 2026. CMS can update the selected services and operating instructions, so confirm each case against the current CMS WISeR Model page and provider guide.
What Is the WISeR Model?
WISeR stands for Wasteful and Inappropriate Service Reduction. CMS describes it as a six-year model running from January 1, 2026, through December 31, 2031.
Technology companies administer the model's prior authorization and pre-payment review process in coordination with Medicare Administrative Contractors (MACs). They may use enhanced technology, including artificial intelligence and machine learning, to support review. Appropriately licensed clinicians make recommendations for non-payment.
The model does not create new Medicare coverage or payment criteria. Reviewers apply existing National Coverage Determinations, Local Coverage Determinations, coding rules, and payment requirements.
That distinction matters. WISeR changes when and how selected services are reviewed, not the legal standard for whether Medicare covers the service.
Which States Are in the Medicare Prior Authorization Pilot?
For the initial performance year, WISeR operates in six states:
| State | Medicare Administrative Contractor jurisdiction | WISeR participant | | --- | --- | --- | | Arizona | JF, Noridian | Zyter | | New Jersey | JL, Novitas | Genzeon | | Ohio | J15, CGS | Innovaccer | | Oklahoma | JH, Novitas | Humata Health | | Texas | JH, Novitas | Cohere Health | | Washington | JF, Noridian | Virtix Health |
The model generally applies based on where the selected item or service is furnished, not simply where the patient lives or where the practice's billing office is located.
CMS began the model January 1, 2026. Participants and MACs began accepting requests on January 5 for selected services furnished on or after January 15, 2026. (CMS WISeR frequently asked questions)
Who and What Does WISeR Cover?
WISeR applies to enrolled providers and suppliers furnishing selected items or services to people with Original Medicare in a model state.
It does not apply to:
- People enrolled in Medicare Advantage
- Every service furnished in a participating state
- Services already handled by another existing CMS prior authorization program
- Inpatient-only services
- Emergency services
- Services CMS determined would create substantial patient risk if delayed
- Railroad Medicare beneficiaries, according to the current operational guide
CMS lists examples of selected categories such as skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. The complete code-level list and any indication-specific limitations appear in Appendix A and Appendix B of the current WISeR Provider and Supplier Operational Guide.
Do not rely on a summary list alone. The same category can contain included and excluded codes, settings, or indications. Confirm the CPT or HCPCS code, diagnosis, site of service, and applicable coverage policy for each case.
The Two WISeR Pathways
Providers and suppliers have two ways to handle a selected service.
Option 1: Request prior authorization
The practice submits the request and supporting documentation before furnishing the service. An affirmed request receives a unique tracking number (UTN) for the claim.
The advantage is payment predictability: the practice receives a provisional coverage determination before the service. An affirmation is still conditional. The claim must match the authorized service and satisfy applicable billing requirements.
Option 2: Furnish the service without prior authorization
The provider may proceed without a prior authorization request. The resulting claim is then subject to pre-payment medical review. The claim can be suspended while the WISeR participant requests and evaluates documentation.
This path does not mean the service is automatically denied. It means the coverage review occurs after the service but before payment, shifting financial and timing risk to the provider or supplier.
For elective services, the practical question is usually whether the clinical circumstances and patient needs support waiting for an advance determination or proceeding with the expectation of pre-payment review.
How Long Does a WISeR Prior Authorization Take?
The current CMS operational guide says WISeR participants plan to issue determinations within:
- Three calendar days for an initial or resubmitted request
- Two calendar days for an expedited request
Submitting through the assigned WISeR participant's portal is the direct route. A provider may instead submit through its usual MAC, but the MAC has to forward the request and decision, which can add time.
These WISeR timeframes are separate from the broader 2026 CMS prior authorization deadlines discussed in How Long Does Prior Authorization Take?. Follow the program governing the actual request.
What Does Affirmed or Non-Affirmed Mean?
An affirmed request means the submitted information supports a provisional determination that the selected service meets applicable Medicare coverage, coding, and payment requirements.
A non-affirmed request means the documentation submitted did not support that provisional determination. It is not the same event as a claim denial.
After a non-affirmation, the provider or supplier can:
- Review the detailed rationale
- Correct or supplement the documentation
- Resubmit the request
- Request peer-to-peer review in connection with a resubmission under the model process
- Decide whether to furnish the service and submit a claim
CMS states that providers have unlimited opportunities to resubmit a non-affirmed request. Existing appeal rights attach if the service is furnished, the claim is submitted, and the MAC issues a claim denial.
The distinction should be visible in the practice's workflow. A non-affirmed request belongs in a documentation or clinical-review queue, not automatically in the claim-appeal queue.
What Documentation Does WISeR Require?
The record must support the applicable Medicare coverage policy. Depending on the item or service, that may include:
- A valid order
- Diagnosis and clinical indication
- Relevant history and examination
- Results of prior imaging or testing
- Conservative treatment and response
- Documentation of why the selected service is reasonable and necessary
- Device trial information where applicable
- Required signatures, dates, and provider identifiers
- CPT, HCPCS, ICD-10, place-of-service, or type-of-bill details
The operational guide includes service-specific examples. The practice should translate the applicable NCD or LCD into an internal checklist without replacing the original policy. When the payer requests evidence, staff should be able to point to the exact chart location supporting each criterion.
The WISeR Exemption Process
CMS is implementing an exemption process for providers and suppliers that demonstrate consistent compliance with Medicare requirements.
The current guide says a provider must submit at least 10 prior authorization requests across selected WISeR items and services during an assessment period and meet the applicable affirmation threshold. CMS indicated that participants would begin issuing exemption-status notifications in June 2026 and add qualifying providers on a quarterly basis.
Because participant instructions and thresholds can change, confirm the current criteria with the participant assigned to your state. Do not assume that a high approval rate automatically creates an exemption until written status is issued.
How a Practice Should Prepare
1. Identify affected services before scheduling
Load the current Appendix A code list into the scheduling or authorization workflow. Include the state and site of service. Flag affected cases as soon as the service is ordered.
2. Map each code to the controlling coverage policy
Record the NCD, LCD, billing article, and documentation criteria staff must use. WISeR does not replace these sources.
3. Choose a submission route
Document whether the practice will submit directly to the WISeR participant or through its MAC. Store portal access, contacts, escalation instructions, and downtime steps in a shared location.
4. Build a complete-request checklist
Define the patient, provider, service, diagnosis, site, documentation, and contact information required before submission. Incomplete requests create avoidable non-affirmations and repeat work.
5. Preserve every acknowledgment and tracking number
Capture submission time, receipt confirmation, participant reference, determination, rationale, UTN, approved code, and date details. Make the information available to scheduling and billing—not only the employee who submitted the request.
6. Reconcile authorization with the claim
Before billing, verify that the claim matches the affirmed request. Check the service, quantity, provider, site, date, and UTN placement.
7. Track outcomes
Monitor affirmation rate, non-affirmation reasons, turnaround, documentation requests, resubmissions, peer-to-peer reviews, pre-payment reviews, claim denials, and payment delay. These measures identify both eligibility for future exemption and internal workflow gaps.
Questions Practice Owners Should Ask
- Do we furnish any current WISeR codes in a participating state?
- Which employee identifies affected cases, and how early?
- Which policy controls each service?
- Can a covering employee assemble the request if our specialist is out?
- Are determinations and UTNs visible to the billing team?
- What is our plan after a non-affirmation?
- When would the treating clinician request expedited review or peer-to-peer discussion?
- Are we tracking the information needed to evaluate exemption status?
The Bottom Line
WISeR is not a nationwide requirement for all Medicare care. It is a targeted, active model for selected Original Medicare services in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
For affected practices, prior authorization is technically optional—but skipping it means the claim enters pre-payment review. The safest operational response is to identify affected services early, build documentation around the governing Medicare policy, preserve the determination and UTN, and keep non-affirmations separate from claim denials.
Greenlight Medical helps private practices turn changing payer and Medicare rules into reliable work queues with clear human review points. Book a free practice operations audit to map the WISeR or prior authorization handoffs your team is managing manually.
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