WISeR Model - Arizona and Washington Providers and Suppliers - JF Part A
WISeR Model - Arizona and Washington Providers and Suppliers
Overview
The Wasteful and Inappropriate Service Reduction (WISeR) Model is a CMS initiative designed to reduce unnecessary and potentially harmful services in traditional Medicare. It leverages artificial intelligence (AI)-enhanced prior authorization and pre-payment medical review to ensure services meet Medicare coverage criteria.
WISeR does not change Medicare benefits or coverage rules. Instead, it introduces a streamlined review process for select services in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. WISeR model participants will be technology companies with expertise in managing prior authorization, with clinical experts available to conduct medical reviews for the service requiring prior authorization.
Key Objectives
The WISeR Model aims to:
- Reduce fraud, waste, and abuse.
- Ensure clinically appropriate care.
- Maintain beneficiary access to necessary services.
- Improve review efficiency using technology.
Who Is Affected?
Providers and suppliers are impacted if they operate in one of the six WISeR states and furnish any of the WISeR select items and services to Original Medicare beneficiaries. Medicare Advantage patients are not affected.
WISeR Participation Options
Providers and suppliers have two pathways:
- Prior Authorization: Submit a request to WISeR participant or MAC. Valid for 120 days.
- Pre-Payment Medical Review: Submit a claim without prior authorization. A determination will be issued within 3 days of receiving documentation.
WISeR Timeline
- Start Date: January 1, 2026
- Prior Authorization Requests Begin: January 5, 2026
- Services Covered: From January 15, 2026
- End Date: December 31, 2031
Included Services
WISeR targets services that have existing coverage criteria, are elective or pose safety risks if misused, and are high-volume or high cost. These services are furnished in hospital outpatient departments (OPDs), ambulatory surgical centers (ASCs), physician offices or in the home setting. These services include:
- Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
- Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
- Induced Lesions of Nerve Tracts (NCD 160.1)
- Vagus Nerve Stimulation (NCD 160.18)
- Phrenic Nerve Stimulator (NCD 160.19)
- Electrical Nerve Stimulators (NCD 160.7)
- Incontinence Control Devices (NCD 230.10)
- Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
- Diagnosis and Treatment of Impotence (NCD 230.4)
- Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (LCD L34106)
- Epidural Steroid Injections for Pain Management (LCD L39240)
- Cervical Fusion (LCD L39758)
- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (LCD L38310)
- Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds and Wound Application of CTPs, Lower Extremities (no Noridian LCDs)
Submitting Prior Authorization
WISeR providers and suppliers will have two options for submitting a prior authorization request:
- Submit a prior authorization request directly to the WISeR participant, or
- Submit a prior authorization request to their designated MAC. The MAC will forward the request to the WISeR participant within 1 calendar day, or as soon as practicable.
Depending on which option is used above, PAR submissions can be made using either the WISeR participant or MAC portal. They can also be submitted via fax, esMD, or mail.
In lieu of requesting prior authorization for WISeR select items and services, WISeR providers and suppliers may choose to provide the select item or service without prior authorization and submit the claim for payment. In this case, the MAC will suspend the claim and forward it to the WISeR participant for pre-payment medical review.
Prior Authorization Review Process
- Standard Review: Decision within 3 days.
- Expedited Review: Decision within 2 days if health is at risk.
- Resubmissions: Unlimited, with peer-to-peer review option.
Claim Submission
- Claims with affirmed prior authorization must include the UTN.
- Claims without prior authorization will undergo pre-payment review.
- Associated services may be denied if the primary service is denied.
Appeals
Non-affirmation decisions are not appealable. Denied claims can be appealed through standard Medicare processes.
Exemptions
CMS may implement automatic exemptions for providers with consistent compliance. Details will be released in future updates.
Special Considerations
An Advance Beneficiary Notice (ABN) is required for expected denials. Claims from VA, IHS, Medicare Advantage, and emergency services are excluded.
