Does your organization provide healthcare services in Ohio, Texas, Arizona, New Jersey, Oklahoma, or Washington?

If yes, understanding CMS’s voluntary WISeR Model is important. It applies to providers in these states providing care to traditional Medicare beneficiaries, and applies when:

• Provide service/item in Ohio, Texas, Arizona, New Jersey, Oklahoma, or Washington and
• Provide service/item in one of these settings: Hospital outpatient department (TOB13x), Ambulatory Surgery Center, Physician’s Office, or Beneficiary’s home and
• Provide a WISeR Select Items and Services from Appendix A, page 37.

The WISeR pilot began on January 5, 2026 and is scheduled to end on December 31, 2031.

WISeR does NOT apply when:

• In a state other than one listed above OR
• Providing services in one of the above settings, yet the claim type will be Veterans’ Affairs, Indian Health Services, Part A/B Rebilling, Emergency OR
• Providing a service/item not listed on Appendices A or B.

Why is it important to understand WISeR?

If no prior authorization is obtained and services are performed, while there are appeal rights if the claim is denied, ultimately, it could result in providing services or items with no reimbursement.

What is the implementation timeline?

Prior authorization acceptance for the WISeR began on January 5, 2026, for dates of service on or after January 15, 2026.

What happens if prior authorization is not obtained before the service or item is provided?

If prior authorization is not obtained before the service or item is provided, the claim will be suspended for prepayment medical review. An additional documentation request (ADR) letter will be sent to the provider, and documentation must be submitted to the Model Participant within 45 days. While the claim may ultimately be paid, it could also be denied, resulting in services provided with no reimbursement. WISeR does not change provider payments or appeal rights.

Upon receipt of Prior Authorization, do I need to do something with the Unique Tracking Number (UTN)?

Yes, the UTN should be reported on the claim.

What is the average turnaround time?

A determination is made within 3-5 days.

Does Medicare as a Secondary Payor require a UTN?

Yes. Submit the claim to the primary insurer. If denied, then submit the claim to the secondary insurer with the UTN.

Are non-affirmation decisions appealable?

No, non-affirmation decisions are not appealable, as they aren’t initial claim determinations. Another prior authorization can be resubmitted. A non-affirmation decision does not prevent a claim submission. Once a claim has been submitted and denied, that is when the appeal process applies.

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With the WISeR Model live, the expectations for providers in participating states will become an essential part of delivering high‑value care. Understanding WISeR isn’t just about meeting regulatory requirements; it’s about protecting your organization from avoidable denials, preventing unreimbursed services, and maintaining a smooth operational workflow in an evolving Medicare landscape. Prior authorization requirements began on January 5, 2026. To prepare, contact one of our experts today.

Lindsay Austin, MBOE, RHIA, Senior Consultant