WISeR Common Questions and Answers - JF Part A

Q1. What is the effective date and duration of the WISeR Model?
A1. The WISeR prior authorization model and medical review started January 1, 2026, with implementation on January 5, 2026, and will continue for six years through December 31, 2031. Submissions began January 5, 2026 for services performed on or after January 15, 2026 and Noridian states includes Arizona and Washington.

Q2. Why is this program being implemented?
A2. CMS is implementing the WISeR Model to reduce unnecessary spending and ensure that only medically necessary procedures are approved for Medicare beneficiaries.

Q3. When does WISeR prior authorization officially begin?
A3. Submissions begin January 5, 2026, for services performed on or after January 15, 2026. This is only for the Noridian states of Arizona and Washington.

Q4. Is Arizona exempt from certain prior authorization requirements?
A4. For the WISeR model, providers have the option to request a prior authorization or not. There is no WISeR exemption at this time; like there is with the Part A Outpatient Department Prior Authorizations.

Q5. What should we do if a pre-authorization is denied? Should we submit additional documentation or start a new request?
A5. If the practice disagrees, request a peer-to-peer discussion. You may also submit a new request with additional evidence or choose not to provide the service.

Q6. During the prior authorization request process, there's a prompt asking for the Type of Service? Where can we locate that list?
A6. Providers can find a complete listing under Section 10.7 of the CMS Internet Only Manual (IOM) Publication 100-04, Chapter 26. It explains the Type of Service (TOS) and indicates either a one-digit numbering (0-9) or alpha (A-W). For example, 2=Surgery and S=Surgical Dressings or Other Medical Supplies.

Q7. How do we request bilateral or repeat procedures?
A7. Request whichever code is appropriate to the service being performed. No need to request the same code multiple times if the documentation indicates it is bilateral. If concerned, submit the single code once and add in multiple units.

Q8. Can Unique Tracking Numbers (UTNs) be reused within the 120-day period?
A8. The UTN will be valid for 120 days. If the request includes repeat services, use the same UTN on claims for up to 120 days.

Q9. Should the CPT entry include the total number of units expected to be performed during the 120-day authorization period?
A9. Yes. For a 120-day timeframe, as that's how long a WISeR Authorization is affirmed.

Q10. Why can't an authorization start date be entered in the future?
A10. The "Authorization Start Date" is the date the authorization is entered, not the date of the procedure. Think of it as "today's date."

Q11. If a procedure is performed on the same day, can it proceed without prior authorization?
A11. Providers and facilities may perform the procedure the same day. Prior authorization under the WISeR Model is voluntary, not mandatory. If a provider does not obtain prior authorization before performing the service, the claim will simply undergo pre-payment medical review after the service is performed.

Q12. How is participation voluntary when Noridian's Q and A says that if you don't request a prior authorization then your claim will be suspended?
A12. If the WISeR claim is just submitted, without an authorization, the claim will be suspended and routed to the Model participant to request documentation to review. Either way, with a prior authorization or not, the model participant will review. Once reviewed, the participant sends the decision to Noridian to finish processing the claim.

WISeR prior authorization portion is voluntary. If the provider doesn't obtain a prior authorization before the procedure, the medical records will be reviewed after the claim is received. The definition of prior authorization is received BEFORE the procedure is performed and that is the voluntary part.

Q13. Can third parties submit the prior authorization requests on behalf of the provider or does the provider need to submit it themselves?
A13. As long as they have written permission from the provider, and applicable patient information to support the procedure, that should be accepted. Templated language for all patients receiving a particular service would not be acceptable. Information would be unique to each patient, including past treatment options when necessary.

Q14. Who is responsible for surgery authorization, the surgeon or the facility? Do outpatient hospitals need to request separate authorizations similar to Ambulatory Surgical Centers (ASCs)?
A14. Either the provider or the facility. The one that obtains the UTN would share it with the other to submit the claim.

Q15. If the ordering provider submits documentation, does it also cover the facility?
A15. The UTN provided on any service review can be used by ASCs or Outpatient Hospitals. Simply add the UTN to the claim form and the WISeR-Selected Service or Item that is affirmed and all associated codes listed in Appendix B of the WISeR Operational Guide will be covered in the authorization.

Q16. Is the UTN valid for both the provider and facility claims?
A16. Yes, The same UTN is good for both the provider and the facility.

Q17. What is the difference between a tracking number and an authorization number?
A17. A UTN is the number you must place on the Medicare claim for WISeR, while the authorization number is the internal WISeR participant approval number that becomes the UTN for claim submission.

Q18. To confirm, the provider's UTN applies only to the CMS-1500 claim, and the facility is required to request its own separate UTN.
A18. The same UTN is used for the patient on both facility and provider/supplier claims. The UTN is approved for the patient and the planned DOS or date ranges.

Q19. Is there a WISeR authorization lookup took available?
A19. Yes. The WISeR CPT and HCPCS codes have been added to Noridian's Prior Authorization (PA) Lookup Tool, allowing users to search codes and see whether WISeR prior authorization applies. The tool is located on the Noridian Medicare website under the Medical Review and Prior Authorization sections for both JF Part A and JF Part B jurisdictions.

Q20. Do we need to follow the WISeR authorization process for every CPT code?
A20. No. Only certain CPT codes, from certain policies, are included in the WISeR model. Refer to the CMS Operational Guide, Attachment A.

Q21. Do we use both Appendix A and B CPT codes for Authorizations?
A21. Yes, both affiliated Appendix A and B can be used. Since WISeR prior authorization is voluntary, if a provider decides to be involved:

• Attachment A codes need prior authorization
• Attachment B codes do not need PA as they are "associated codes"

However, note that if a code from Attachment A is denied, the associated code from Attachment B will also be denied.

Q22. Have skin substitutes been removed from requiring prior authorization under WISeR?
A22. Skin substitutes have been removed as a category for review from the Operational Guide for the states of Arizona and Washington. Noridian has also removed the draft Local Coverage Determination (LCD) policy.

Q23. Can you confirm whether Arizona ASC providers must follow two separate prior authorization programs?
A23. Each prior authorization program has different codes. The ASC prior authorization is a requirement, where the WISeR model is voluntary to request a prior authorization. The ASC Prior Authorization Demonstration Service Categories include:

• Blepharoplasty
• Botulinum Toxin Injections
• Panniculectomy
• Rhinoplasty
• Vein Ablation

Q24. How do we verify ASC-related authorization requirements when portal data appears inconsistent?
A24. The WISeR prior authorization requests for service performed in an ASC are separate from the ASC prior authorization for certain services.

Q25. If services are rendered at the ASC under Part B, does an ASC request their own authorization?
A25. Yes. For WISeR, when services are rendered at an ASC under Part B, the ASC must request its own prior authorization.

Q26. What are the risks of WISeR causing delays in patient care?
A26. WISeR is trying to minimize risk with the AI-driven pre-authorization of certain policies and certain CPT codes within. The risks could involve necessary treatment delays and increasing administrative burden.

Q27. The Noridian Medicare Portal (NMP) User Manual does not contain WISeR specific information. Under the Prior Authorizations (Part B), Portal Guide, Noridian indicates "Part B Prior Authorizations are only available for HCPCS Codes A0426 and A0428." Where can we find the WISeR information?
A27. WISeR is a model separate from the Noridian Medicare Portal. CMS contracts with third-party vendor "Model Participants" to review certain services and the Participant has a separate portal. Providers may find more information in WISeR Model Provider and Supplier Operational Guide.

The HCPCS above are for the Ambulance "Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT)" special prior authorization.

Q28. Where can I find what services need to be submitted to WISeR?
A28. Providers can read the CMS WISeR Operational Guide WISeR Model Provider and Supplier Operational Guide for more information. Also, on Noridian's Medical Review / Prior Authorization pages under WISeR. Certain policies with certain services are listed.

Q29. What are the HIPAA implications of uploading patient information to the portal?
A29. There are no HIPAA implications. CMS has contracted with the Participants and their contracted employees, along with their portals, to be HIPAA compliant.

Q30. What information is required when submitting a request via upload or fax?
A30. Please refer to the WISeR Prior Authorization Request Coversheet found under Forms on the Noridian website.

Q31. Where is the long member ID number generated?
A31. If the 11-digit member ID number required for WISeR Review, that is the Medicare Beneficiary Identifier (MBI) ID number found on their Medicare Card.

Q32. If a hospital is located in Arizona, but has WPS as their MAC rather than Noridian, are these hospitals included in WISeR?
A32. CMS set the WISeR model up by state. If the procedure is performed in Arizona, and you choose to request a prior auth, that would need to be submitted (to that MAC or Noridian).

Q33. What if we need to perform a "prior authorization" procedure on the same day and cannot wait the two-three days for approval?
A33. Perform the procedure and remember, that the prior authorization is an option and not required for the WISeR model.

Q34. What does Type of Bill (TOB) and what needs to be reflected?
A34. Under Part A UB-04, TOB includes WISeR procedures that can be performed Office, Hospital Outpatient Department (HOPD), Ambulatory Surgical Center, or Home. The location of service will determine the claim type that will be submitted. For example, HOPD is submitted on a 13x claim. It assists when services are also performed in various locations.

Q35. Which portal would providers and suppliers send their prior authorization (PA) requests and check status?
A35. Providers and suppliers may submit their PA requests directly to their WISeR Model Portal (WMP) at the third party vendor participant site (AZ-Zyter; WA-Virtix) or Noridian via fax, mail, or portal as indicated in the Provider and Supplier Guide.

However, regardless of the submission method, the WMP's PA status is the only way the it can be tracked. WMPs make the WISeR determinations. For this reason, we encourage providers and suppliers to register with their respective WMP portal to submit or at least track.

Q36. Is the coversheet located on the Noridian Forms page mandatory?
Q36. The Noridian Prior Authorization Request (PAR) Form is not required; but a tool to make sure all the necessary information is included in the PAR. As long as providers are reflecting the CMS Operational Guide requirements, they may create their own coversheet.