When will WISeR participant electronic portals be operational? (NEW)
WISeR participant electronic portals are important to give providers and suppliers in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, options for making prior authorization requests under the WISeR model. CMS is working closely with WISeR participants to implement their portals by January 5, 2026, and test for readiness. CMS is firmly committed to ensuring timeliness, accuracy, and transparency under the WISeR model, and will take corrective actions as appropriate to ensure these goals are met. CMS will continue to work with providers, suppliers, and WISeR participants to ensure that any issues are rapidly identified and resolved. WISeR participants that are unable to deliver active WISeR participant electronic portals will face consequences, e.g. payment penalties or other corrective actions.
How will providers submit prior authorization requests if their WISeR participant electronic portal is not yet open? (NEW)
Until WISeR participant electronic portals are open, providers and suppliers can submit prior authorization requests through their MAC, which may take longer than 72 hours as described in the FAQ below. CMS is working closely with MACs to ensure they are ready to forward prior authorization requests to WISeR participants and forwarding decisions back to the provider timely.
Alternatively, providers and suppliers may choose not to submit a prior authorization request. If a provider or supplier chooses not to submit a prior authorization request for an included service, their claim for the service would be subject to pre-payment medical review for any date of service on or after January 15, 2026.
When will the 72-hour turnaround time for a prior authorization request sent to a provider portal apply? (NEW)
The 72-hour turnaround time for requests sent to a WISeR participant electronic portal applies starting January 5, 2026, for dates of service on or after January 15, 2026. As CMS works with WISeR participants and providers and suppliers on the testing of the WISeR participant electronic portals, CMS will monitor turnaround time and compliance with this requirement, and failure to comply with the turnaround time will result in corrective action. (Note: the 72-hour turnaround time applies to the WISeR participant. For prior authorization requests sent to a MAC rather than through a WISeR participant electronic portal, additional time may be needed for the MAC to process and forward the information to the participant, and then to forward the decision back to the provider/supplier.)
How were states selected to participate in the WISeR Model?
States and regions were selected based on comparison feasibility, service volume, and geographic diversity and presence or absence of selected services. States included in the model were selected to ensure a broad array of practice environments and geographies. In addition, CMS reviewed Medicare Administrative Contractor (MAC) jurisdiction and LCDs or NCDs within each selected state to ensure that the model could be fully tested. For the initial performance year, which began on January 1, 2026, the WISeR Model operates in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
What is the planned timeline for WISeR, and what resources are available for providers?
WISeR is a 6-year model, which launched on January 1, 2026, and will continue until December 31, 2031. The application period closed on July 25, 2025, and CMS announced participants on November 6, 2025. The participant list is available on the WISeR model website.
The WISeR Provider and Supplier Operational Guide (PDF), available on the model website, contains information about the prior authorization and pre-payment review process as well as Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes and clinical documentation requirements for the services included in WISeR. This guide will be updated periodically throughout the model as needed.
CMS is also partnering with the selected MACs and model participants to provide additional education materials and resources. Providers delivering services in a WISeR state can reach out to their MAC (Noridian, Novitas, CGS) and model participant for more information.
How will the transition to WISeR be managed for patients who initiated care in 2025 and will continue receiving services into 2026?
The WISeR Model began on January 1, 2026. WISeR participants and MACs began accepting prior authorization requests from WISeR providers and suppliers on January 5, 2026, for services rendered on or after January 15, 2026. This later date is intentional and is designed to allow sufficient lead time to process requests and ensure adequate time for scheduling affirmed services. Only those services provided on or after January 15, 2026, that have been appropriately authorized under WISeR will be reviewed as part of the model. Services delivered prior to January 15, 2026, were not subject to the WISeR Model.
Does WISeR impact professional service fees and payment rates for providers?
No, WISeR does not change Medicare payment rates for the included items or services. The WISeR Model does not change coding and policy changes made as part of Medicare’s payment rules, for example the Physician Fee Schedule, as well as changes to the selected National and Local Coverage Determinations as part of Medicare coverage criteria.
How are associated codes and ICD-10 diagnoses handled? Would a code that is on the associated service list be flagged independently or as a standalone service?
The "primary codes" in Appendix A of the WISeR Provider and Supplier Operational Guide (PDF) are subject to prior authorization and pre-payment review in WISeR selected states.
Associated codes are related to a WISeR item or service. The associated codes in Appendix B are not designed to be treated as standalone services and will not require separate prior authorization or pre-payment review on their own. Claims for associated codes will be paid (assuming all existing requirements relevant to the associated codes are met) if a primary code for a WISeR select item or service is affirmed during prior authorization or approved during pre-payment review. Claims for associated codes will be denied and/or payments for associated codes will be recouped if a primary code for a WISeR select item or service has a non-affirmed prior authorization or is denied during pre-payment review.
Appendix C contains ICD-10 codes for a subset of WISeR services; they narrow the CPT codes for the services selected in WISeR to align with the relevant NCD or LCD. For those services, CPT codes billed without an ICD-10 code on Appendix C are out of scope and will not be included in WISeR.
In which sites of service will the WISeR Model be implemented? What differences are there between professional and facility claims in WISeR?
The WISeR Model is in place for claims from Hospital Outpatient Departments (HOPDs), Ambulatory Surgery Centers (ASCs), office and home settings in selected states. For services delivered in HOPDs or ASCs, prior authorization and pre-payment review will be implemented for the facility-based encounter or claim, though professional claims can later be flagged through the associated code list in the case of any non-affirmed or denied facility claims. Meanwhile, professional encounters and claims will be subject to prior authorization and pre-payment review for services delivered in the office or home in selected states.
How does WISeR plan to address any policy changes, particularly those related to skin substitutes?
WISeR aligns to the existing selected NCD or LCD for each of its items and services. WISeR states with an active LCD covering skin substitutes include skin substitutes as a service for prior authorization and pre-payment review under the model. WISeR states that do not have an active skin substitute LCD do not include skin substitutes as a service in the model. WISeR will continue to align to any changes that do occur to the LCDs. As needed, any changes will be reflected in an updated version of the WISeR Provider and Supplier Guide on the WISeR website
Where can providers/suppliers go to review each step of submitting an authorization and understand who is responsible at each stage?
For a clear understanding of the prior authorization process for WISeR, please reference the WISeR Provider Factsheet (PDF). The fact sheet includes a comprehensive flow chart that visually outlines the prior authorization process, so providers/suppliers know what to expect and whom to contact throughout the process. For further details, please see the WISeR Provider and Supplier Operational Guide (PDF); providers can also reach out to their relevant MAC or model participant.
What is the process and timeline for WISeR prior authorization determinations, including beneficiary notifications for non-affirmed services and procedures for expedited reviews?
WISeR participants will typically issue a determination to the requester within three (3) days of receiving the initial or resubmitted request. In general, the determination (with the Unique Tracking Number that would get submitted with the claim) will be sent in the same manner in which the prior authorization request was submitted (e.g., via postmark, fax, or electronic delivery). Requests sent directly to the model participant and/or through mail may take longer due to additional processing steps.
The requester may submit a prior authorization request for expedited review with the applicable documentation if delays could seriously jeopardize the beneficiary’s life or health. If the WISeR participant confirms this risk, then the WISeR participant will process the prior authorization request and communicate a decision to the requester within two (2) days of receipt of the expedited request. Since WISeR focuses on nonemergent services only, CMS expects requests for expedited reviews to be rare.
If the service is non-affirmed during prior authorization, then the physician will be required to notify the beneficiary through an Advanced Beneficiary Notice of Non-Coverage (ABN) before furnishing the service. All appeals rights are preserved under WISeR and the provider and beneficiary have the right to appeal any denied claims.
What documentation and materials are required to be included when submitting a prior authorization request (e.g., cover sheets, specific forms, supporting clinical information, medical recommendations)?
Medicare providers and suppliers who are submitting a prior authorization request under the WISeR Model must include a completed cover sheet or designated request form, along with detailed beneficiary information, including the patient’s full legal name, Medicare Beneficiary Identifier (MBI), date of birth and address. The submission must also include facility and provider details (names, addresses, National Provider Identifiers [NPI], and PTAN/CCN numbers), along with current contact information for the requester. The submission must clearly specify the service by including the relevant CPT/HCPCS code, corresponding diagnosis codes, anticipated place of service, the units of service to be performed within 120 days, and whether the request is an initial review or a resubmission. If expedited processing is requested, documentation explaining the urgent health risk must be attached. Comprehensive supporting clinical information such as recent visit notes, relevant lab or imaging results, medical necessity rationale, prior treatment history, and current treatment plans should be included for the service requested, as needed. Finally, submission of all additional materials or forms specified by the MAC or WISeR participant can help prevent delays; submitting an organized and complete request helps facilitate a timely and accurate determination.
How do technology companies participating in WISeR evaluate and process prior authorization requests?
After receiving a prior authorization request, either directly from the provider/supplier or routed through the MAC, the model participant will then conduct the prior authorization review. A human clinician with relevant clinical expertise for selected items and services must review every non-affirmation. To be provisionally affirmed, the request for prior authorization must meet all applicable Medicare rules and policies including those defined in the clinical documentation requirements as set forth in the WISeR Provider and Supplier Operational Guide (PDF).
Who will perform the peer-to-peer review, and when will these reviews be available during the prior authorization process?
The WISeR Model allows for peer-to-peer review as part of the resubmission process, where the requesting physician has an opportunity to engage in a discussion about an item or service’s medical necessity before a final determination is made by the WISeR Model participant. Medicare providers and suppliers can request peer-to-peer review as part of a resubmission, and this would be subject to same timeframes for standard and expedited requests. CMS will audit participants to prevent inappropriate denials, and participants will be held accountable to a performance metric related to accuracy of determinations.
What is the exemption program (or “gold carding”)?
WISeR is planning to launch a ‘gold carding’ or exemption program in 2026. Under the WISeR gold carding or exemption program, providers and suppliers who consistently meet coverage criteria by achieving a certain affirmation threshold associated with their prior authorization requests will generally be exempt from any additional prior authorization and pre-payment review processes for the selected items and services in WISeR. Providers and suppliers who achieve gold card or exemption status will be able to maintain it for a defined period of time before undergoing re-evaluation to ensure they continue to meet Medicare coverage criteria for those selected WISeR services.
Does WISeR change Medicare coverage policy?
No. Instead, WISeR supports the accuracy and efficiency of CMS’s review for compliance with existing coverage policy in statutes, regulations, National Coverage Determinations, and Local Coverage Determinations. All providers and suppliers are expected to adhere to these policies when providing services to Medicare beneficiaries.
Health care coverage for people with Medicare will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice. Payment to providers and suppliers for covered services will not change under the model.
Does WISeR apply to all items and services in Original Medicare?
No. WISeR targets a narrow set of items and services that have been a source of fraud, waste, abuse, and inappropriate utilization, and which can present a very real threat of patient harm. Examples include skin substitutes, knee arthroscopy for knee osteoarthritis and electrical nerve stimulation. The list was derived through a careful review of existing National and Local Coverage determinations, clinical and academic literature, and reports from the U.S. Department of Health and Human Services (HHS) Office of Inspector General.
How does WISeR protect patients?
A primary goal of WISeR is to help patients avoid unnecessary, inappropriate procedures that may cause potential harm such as pain, bleeding, infection, anxiety, or other adverse effects and instead promote high-value services aligned with evidence-based care guidelines.
WISeR applies to a narrow set of items and services that: 1) may pose concerns related to patient safety if delivered inappropriately; 2) have existing publicly available coverage criteria; and 3) may involve prior reports of fraud, waste and abuse.
The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed. However, a provider or supplier may request an expedited review, if needed.
Monitoring metrics for WISeR participants will promote patient safety and appropriate care, including holding model participants accountable for their accuracy on determinations and ensuring they are not unnecessarily increasing inappropriate denials.
Bottom line: Most health care providers prioritize patient health and safety over profit. But, an unfortunate truth, as evident by past law enforcement cases, is that some health care providers abuse Medicare by providing expensive items or services, like skin substitutes or implantation of electrical nerve stimulators, in situations where the patients may not benefit and where they do not meet Medicare coverage criteria. WISeR will proactively curtail these practices.
How will WISeR streamline current coverage review for both people with Medicare and providers?
WISeR is intended to improve speed, accuracy and consistency of review for adherence to existing coverage policy by leveraging technology to determine whether a claim is payable before services are rendered for providers who opt for prior authorization, or before payment is made for providers who do not opt for prior authorization.
The aim is to drive towards ‘auto-approvals’ of requests, wherever possible. Most response times will be within 72 hours, and, in many cases, the response will be much faster.
Benefit to Patients: Patients receive a fast, accurate determination of whether certain services are reasonable and necessary, promoting safety and the most appropriate, effective care for their conditions.
Benefit for Health Care Providers and Suppliers: Health care providers and suppliers who opt for prior authorization will know in advance that they will be paid for the services they are delivering so long as all of the applicable Medicare coverage and clinical documentation are met, and the claim was billed and submitted correctly. CMS, in conjunction with model participants, will offer provider education for transparency and predictability. Providers and suppliers with a demonstrated record of compliance may receive a limited exemption or “gold card” from the WISeR full review process in the future. This will help ensure the model focuses on providers and suppliers at higher risk of delivering unnecessary and potentially unsafe care.
How will WISeR ensure Medicare savings?
Model participants will only be compensated if they reduce wasteful, inappropriate care, receiving a percentage of the savings associated with their reviews. At the same time, CMS will perform rigorous oversight, and participants will be financially penalized for inappropriate denials.
How will WISeR safeguard against inappropriate non-affirmations (denials)?
Non-affirmations will require the review of a human clinician and cannot be performed solely by technology. Moreover, the payment methodology disincentivizes inappropriate non-affirmations in several ways:
- CMS will audit participants to ensure that determinations are consistent with Medicare coverage criteria. Audit results contribute to participants’ quality scores, resulting in negative payment adjustments for inaccurate determinations. Further, participants who have a high rate of inaccuracy may be terminated from the model.
- Model participants are responsible for the cost of processing prior authorization requests, including unlimited resubmissions of a non-affirmed request.
- Participants will only be paid once per beneficiary, regardless of the number of resubmissions, which incentivizes an accurate determination at the time of the first request.
- Providers, suppliers, and beneficiaries will retain their rights to appeal any denied claims and participants will not be paid (or will have payments recouped) for any non-affirmations followed by a successful claims appeal.
How will WISeR protect beneficiary data?
The Wasteful and Inappropriate Service Reduction (WISeR) Model reflects the CMS Innovation Center’s commitment to protect federal taxpayers and the Department of Health and Human Services (HHS) and CMS pledge to protect people with Original Medicare by crushing fraud, waste and abuse. In addition to saving taxpayer dollars, the model aims to reduce inappropriate, unnecessary and invasive procedures (in line with existing Original Medicare prior authorization policy) that can significantly harm patients while also improving upon the existing prior authorization process to streamline efficiency and improve accuracy by leveraging enhanced technologies.
Moreover, CMS has policies and procedures that limit model participants’ access and use of Personally Identifiable Information (PII) and Protected Health Information (PHI), in accordance with the Privacy Act of 1974, HIPAA regulations, and other applicable federal laws.
How else will participating companies be held accountable?
While enhanced technology aims to expedite the prior authorization process, any recommendations that coverage should not be provisionally affirmed will be made by an appropriately licensed human clinician, not a machine. If the item or service is provided, providers, suppliers and people with Medicare will have the ability to appeal claims decisions as usual. Participating companies will be held to requirements such as:
- demonstrated ability to interpret and apply clinical coverage criteria derived from National Coverage Determinations or Local Coverage Determinations;
- experience using enhanced technology, including with other payers or health plans, to streamline approval processes;
- ensuring appropriate clinical expertise is incorporated into the pre-approval process and to conduct medical reviews; and
- capability to offer back up options to advanced technologies, including phone, fax, electronic portals and regular mail.
How does WISeR align with the HHS Secretary Robert F. Kennedy, Jr’s and CMS Administrator Dr. Mehmet Oz’s pledge to fix the prior authorization system.
Prior authorization can ensure that beneficiaries receive timely access to services that are medically necessary, clinically appropriate, and evidence-based when applied in a targeted manner. The Kennedy pledge is about the right balance for review: enough to protect patients but not so much that it interferes with their timely access to medically necessary care:
- WISeR models best practices in Original Medicare for how to conduct prior authorization. It zeroes in on those services that are vulnerable to waste and abuse—and have the possibility of being harmful to patients if misused—because of inadequate implementation of existing statutes, regulations, National Coverage Determinations, and Local Coverage Determinations.
- Medicare Advantage reforms aim to reduce prior authorization where it has become unnecessary and burdensome to patients and providers.
While WISeR applies to Original Medicare and the pledge applies to Medicare Advantage, the model aligns with the pledge’s goals to:
- Enhance transparency and communication around authorization decisions and appeals.
- Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027.
- Ensure medical professionals review all clinical denials.
Why did CMS develop WISeR?
The WISeR model reflects the CMS Innovation Center’s commitment to protect federal taxpayers and the Department of Health and Human Services (HHS) and CMS pledge to protect people with Original Medicare by crushing fraud, waste and abuse. In addition to saving taxpayer dollars, the model aims to reduce inappropriate, unnecessary and invasive procedures (in line with existing Original Medicare prior authorization policy) that can significantly harm patients while also improving upon the existing prior authorization process to streamline efficiency and improve accuracy by leveraging enhanced technologies.
How does WISeR fit into the Innovation Center Strategy?
WISeR addresses all three pillars of the Innovation Center’s strategic direction to:
- Promote evidence-based prevention by introducing clinical review with enhanced technology to ensure patients are receiving the most appropriate and effective care, which can include focusing more on prevention and less on costly, potentially invasive and inappropriate care.
- Empower people to achieve their health goals by setting the stage for beneficiaries partnering with their clinicians on the most effective care plans and, where possible, providing them with more information about their care.
- Drive choice and competition for people by applying new tools in Original Medicare; and by incentivizing participating companies to help deliver fast, accurate, transparent prior authorization decisions and holding those companies accountable for their performance.
Moving forward, the Innovation Center will prioritize the role of technology in improving quality and reducing cost.
How will providers or suppliers in model test regions submit a prior authorization request?
Providers or suppliers in a designated region for the model who choose to submit a request for covered services will send all relevant information to support Medicare coverage of the selected services either directly to the company participating in WISeR for that region or to their Medicare Administrative Contractor (MAC), which will then route it to the model participant.
The model participant will use enhanced technology to support coverage determinations and seek medical review by clinicians with relevant expertise, as needed. Model participants will notify the provider or supplier of the decision.
Providers and suppliers, however, are not required to submit a prior authorization request for a selected service. Should they choose not to, the claim for that service would be subject to post-service/pre-payment medical review.
How can a provider, supplier or beneficiary appeal a decision?
For a “non-affirmed” prior authorization request — meaning that a future service was found not to meet Medicare coverage, coding or payment requirements — the provider/supplier has unlimited opportunities to resubmit a request. A non-affirmed decision does not prevent the provider/supplier from delivering the service and submitting a claim. Submission of such a claim and denial by the MAC will constitute an initial payment determination, which would be subject to the existing administrative appeals processes available to providers, suppliers and people with Medicare.
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