Prior Authorizations - WISeR

Available For: Part B

Arizona and Washington Part B users may submit a request for a Prior Authorization for the WISeR Model services by completing the Prior Authorization Request Form.

Choose Prior Authorizations from the Main Menu and then the Submit New Prior Auth Tab.

Submit New Prior Authorization Request

Provider/Supplier Details

Directions: Choose the Provider/Supplier Details of the facility participating in the WISeR Model for which you are submitting, and the Unique Tracking Number (UTN) will be assigned. Your NMP account must be registered with this information to review the request after submission.

  • TIN or SSN
  • NPI
  • PTAN
  • Program - Ensure MEDB is selected

Beneficiary Details (As it appears on Medicare Card)

Directions: Enter the beneficiary information as it appears on their Medicare card. Ensure all submitted medical records have the same spelling and date of birth as entered.

  • Medicare Number
  • First Name
  • Last Name
  • Date of Birth
  • State of Residence (Not required)
  • Sex (Not required)

Requestor Details

Directions: The requestor is the person that is submitting the request, this could be the office manager, prior authorization specialist, etc.

  • Requestor Full Name/Provider Name
  • Requestor Phone
  • Requestor Email Address
  • Requestor Fax Number
  • Requestor Address
  • Requestor City
  • Requestor State
  • Requestor Zip

Facility/Ambulance Supplier Details

Directions: Enter the facility information that is participating in the WISeR Model as entered in the above section: Supplier/Provider Details. These must be the same as the section above.

  • Name
  • PTAN
  • NPI
  • Address
  • City
  • State
  • Zip
  • Physician/Practitioner Fax Number (Not Required)

Prior Authorization Request Details

  • Prior Auth Request Type - Choose WISER
  • Procedure Code - Enter all CPT/HCPCS codes and Units that require prior authorization for the planned date of service. Modifiers are only optional for Prior Authorizations.
  • Diagnosis Code Details - *Required* Enter the diagnosis code pertinent to the WISeR service
  • Place of Service
  • Type of Service
  • Specialty Code
  • Anticipated Date of Service
  • Is this an Initial Request or a Resubmission - Select Initial Request or Resubmission. If Resubmission, enter Previous UTN.
  • Expedited Request? - Select Yes or No. Expedited Requests require justification to meet expedited requirements.

Upload Supporting Document

Ensure all medical records have accurate name and date of birth.

File size is limited to 70 MB.

File types supported are GIF, JPG, JPEG, TIF, TIFF, DOC, DOCX, XLS, XLSX, PDF. File name is limited to 40 characters and should help the user identify the document and its purpose at a later date.

Tip
If multiple documents are needed for supporting documentation, combine all files into one file (if under 70 MB in size). This will eliminate the need for multiple uploads.
  • Document Name - Limited to 40 characters length.
  • Selected File - Browse your computer for the documentation.

Once all information is completed and documentation is attached, Choose Submit.

Once the request has been submitted, a Reference Number will be provided.

Status inquiries on WISeR Model Prior Authorization Requests CAN NOT be performed in NMP. Users may reach out to your assigned WISeR model participant.

  • Arizona - Zyter Trucare
  • Washington - Virtix Health

View the WISeR Model page for more information.

Last Updated Feb 04 , 2026