WISeR Model - Arizona and Washington Providers and Suppliers

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.

CMS contracted directly with external WISeR Participant technology companies to conduct review and prior authorization activities. Providers should direct all questions related to a WISeR service to their state's assigned Participant.

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.

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

Prior authorization is voluntary. The WISeR identified procedure will be reviewed once the claim is received if prior authorization was not obtained. Providers and suppliers have two pathways to receive coverage determinations:

  • Prior Authorization: Submit a voluntary request to the WISeR participant (preferred) or Noridian. Valid for 120 days.
  • Pre-Payment Medical Review: Submit claim without prior authorization. Determination is issued within three 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. For Noridian, these services include:

  • 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 L34228)
  • Epidural Steroid Injections for Pain Management (LCD L39240)
  • Cervical Fusion (LCD L39758)
  • Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (LCD L38310)

A complete list of select services and corresponding codes can be found in Appendices in the WISeR Model Provider and Supplier Operational Guide, located in the resource section below.

  • Appendix A - WISeR items and services with CPT or HCPCS codes included in review
  • Appendix B - ICD-10 indications for relevant WISeR items and services
  • Appendix C - WISeR associated codes list

Providers may also use the Prior Authorization Look-Up Tool to determine if a code is included in the WISeR program.

Submitting Prior Authorization

WISeR providers and suppliers have two options for submitting a prior authorization request:

  1. Submit a prior authorization request directly to the WISeR participant, or
  2. Submit a prior authorization request to their designated MAC. The MAC forwards the request to the WISeR participant within one calendar day, or as soon as practicable. The WISeR form includes information needed for this process and can be found on the Medical Review Forms page.

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.

  • Noridian WISeR dedicated fax: 701-433-3366
  • Noridian mailing address:
    • Noridian JF Part A
      Attn: Medical Review - WISeR
      PO Box 6782
      Fargo, ND 58108-6782
    • Noridian JF Part B
      Attn: Medical Review - WISeR
      PO Box 6700
      Fargo, ND 58108-6700

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.

Third parties may submit a request on behalf of the provider as long as they have written permission, and applicable patient information to support the procedure. Templated language for all patients receiving a particular service is not acceptable. Information would be unique to each patient, including past treatment options when necessary.

Completing the Request

  • Part A or Part B Request:
    • Part A: Services performed in an outpatient hospital. The rendering provider may request on behalf of the facility and must use the facility NPI and PTAN.
    • Part B: Services performed in places of service ASC (24), office (11), or patient home (12).
  • Facility Information: Complete this section if performed in an outpatient hospital (Type of Bill 13X) or ASC (place of service 24). The facility is responsible for submitting the UTN on the claim. Rendering provider must be identified but will not submit the UTN on their claim.
  • Requestor Information: include the information for the person submitting the prior authorization.
  • Bilateral Procedures: Request whichever code is appropriate to the service being performed. There is no need to request the same code multiple times if the documentation indicates it is bilateral. Submit a prior authorization for the single code once and if approved, submit the claim using the appropriate laterality modifiers (i.e., RT, LT, 50).
  • Number of Units: The CPT entry should include the total number of units expected to be performed during the 120-day timeframe.
  • Ambulatory Surgical Center (ASC): For WISeR, when services are rendered at an ASC under Part B, the UTN must be submitted only on the ASC claim. The ASC or the rendering provider can request the prior authorization on behalf of the ASC.
  • The Noridian Prior Authorization Request Coversheet is not required; however, it contains all of the necessary information. Providers may create their own coversheet as long as all of the CMS Operational Guide requirements are met.

Review Process

  • Standard Review: Decision within three days.
  • Expedited Review: Decision within two days if health is at risk.
  • Denied Requests: Request peer-to-peer review, resubmit with additional evidence, or choose not to provide the service.
    • If a code from Attachment A is denied, the associated code from Attachment B is also denied.

Unique Tracking Number (UTN)

  • Affirmed requests are assigned a UTN by Noridian within two business days of receiving the file from the WISeR Participant.
  • Valid for 120 days from the effective date.
    • Effective date determined by decision date of affirmed or non-affirmed.
    • Effective date is not the date the request was submitted.
  • UTN format
    • 14-digits
    • Starts with zero, not letter
    • Third digit will be letter A, B, C or D
    • Digits 4-14 are numbers

Claim Submission

  • Claims with affirmed prior authorization must include the UTN.
  • Part A claims (13X TOB):
    • Part A claims submitted in the Fiscal Intermediary Standard System (FISS)/Direct Data Entry (DDE):
      • Enter UTN in the treatment authorization field on DDE Page 05 (MAP1715).
    • Paper (UB-04) claims:
      • TAB to the second field of the treatment authorization field (positions 19 - 32) and key the UTN:
      • Do not enter the UTN in positions 1 - 18:
      • Digits in this position will be converted to zeros and the claim will not be accepted.
  • Part B claims (places of service 11, 12, 24)
    • Electronic claims
      • Submit the UTN in the 2300 - Service Line loop in the prior authorization reference (REF) segment:
        • REF01 = "G1" qualifier
        • REF02 = UTN (14-byte)
    • Paper claim (CMS-1500) submissions:
      • UTN must populate the first 14 positions in item 23.
      • All other data submitted in item 23 must begin in position 15.
  • 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.

Gold Card (Exemptions)

Effective July 6, providers achieving certain affirmation thresholds may be eligible to be exempt from WISeR reviews. Only the WISeR Participant can provide the Gold Card. Check with the WISeR participant for individual provider exemptions.

Exemptions from other prior authorization programs are not recognized in the WISeR model.

Special Considerations

An Advance Beneficiary Notice (ABN) is required for expected denials. Claims from VA, IHS, Medicare Advantage, and emergency services are excluded from WISeR review.

Resources

Last Updated Jul 22 , 2026