For most of its history, Original Medicare used prior authorization sparingly. Medicare Advantage plans and commercial payers made it a daily workflow. However, fee-for-service Medicare mostly paid first and reviewed later. The CMS WISeR Model changes that for providers in six states. If your practice delivers a selected service in an affected state, authorization now affects scheduling, documentation, and cash flow. It is no longer just a back-office task.
This guide explains what WISeR is and where it applies. It also covers how the process works and how to prepare your team. If you want a refresher first, start with our complete guide to prior authorization in medical billing.
Key Takeaways
- WISeR tests prior authorization and prepayment medical review in Original Medicare for a limited set of services, in six states.
- The six states are Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The model period runs January 1, 2026 through December 31, 2031.
- It applies to Original Medicare, not Medicare Advantage.
- The practices that cope best assign clear ownership, track every request, and keep documentation complete before scheduling.
What Is the CMS WISeR Model?
WISeR stands for the Wasteful and Inappropriate Service Reduction Model. It is a CMS Innovation Center model that tests technology-enabled prior authorization in traditional Medicare. According to the Congressional Research Service, the model pairs machine learning with human clinical review. Together, they decide whether selected services are appropriate for Medicare payment.
CMS introduced the model to address low-value care. Its own materials estimate that waste makes up roughly 25 percent of U.S. health care spending. As a result, the model focuses on services CMS considers vulnerable to waste, fraud, and patient harm. Still, some providers and patients disagree with how CMS classifies certain services as low value. That is one reason the model has drawn debate.
Two pathways sit inside the model. Providers can submit a prior authorization request before the service, or they can accept prepayment medical review when the claim is submitted. Both are covered below.
The most important clarification: WISeR concerns Original Medicare. It excludes Medicare Advantage patients. It also excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.
When Did the WISeR Model Start?
The model period is January 1, 2026 through December 31, 2031. Per CMS operational timelines, prior authorization submissions opened on January 5, 2026. The applicable services became subject to the process on January 15, 2026. Because operational details can change, always verify dates against the current CMS operational guide.
Which States Are Included in the WISeR Model?
WISeR operates in six states:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
These states sit within four Medicare Administrative Contractor (MAC) jurisdictions. CMS selected them so each could be compared with non-model states in the same claims processing region. Your location and the specific service determine whether the model applies. Therefore, do not assume a service is in scope just because it is in the right state. In addition, some items, such as skin and tissue substitutes, apply only where an active Local Coverage Determination is in place.
Also, practices that operate across multiple states should treat each location separately. Our breakdown of eligibility verification errors shows how easily payer-rule mix-ups turn into denials.
Which Medicare Services May Require Prior Authorization?
CMS targets a narrow set of outpatient services with high rates of improper payment or low clinical value. Categories in CMS and CRS materials include electrical nerve stimulation and steroid injections for pain. Others include destruction of nerve tissue, bone cement injections for vertebral compression fractures, skin and tissue substitutes, and knee arthroscopy for certain indications.
Do not rely on a blog list for scope. The authoritative source is the service and code list in the CMS WISeR Provider and Supplier Operational Guide. CMS can update it at any time. Therefore, build your internal process around that document, not around a summary.
WISeR Prior Authorization Checklist
- Confirm the beneficiary has Original Medicare (not Medicare Advantage).
- Check the current WISeR service list for your state.
- Validate procedure and diagnosis codes against that list.
- Collect the clinical documentation required for the service.
- Submit before scheduling when appropriate.
- Monitor the decision.
- Escalate requests for additional information quickly.
- Record the outcome in the billing workflow.
Accurate coding is the foundation of this checklist. Our guide to CPT, ICD-10, HCPCS codes, and modifiers is a useful companion for the validation step.
How Does the WISeR Prior-Authorization Process Work?
- Verify eligibility and WISeR applicability. Confirm coverage type, state, and MAC jurisdiction.
- Confirm the service is included. Check the current CMS list, including any LCD conditions.
- Gather clinical records. Collect notes, test results, and medical-necessity support before submission.
- Submit the request. Send it through the process the assigned WISeR participant requires.
- Monitor status. Respond promptly to requests for additional information.
- Record the decision. Capture the outcome and any reference numbers in one place.
- Coordinate scheduling and billing. Make sure clinical, front-desk, and billing teams all see the decision.
- Address non-affirmed decisions or prepayment review. Decide whether to resubmit, appeal, or adjust the care plan.
CMS has stated that providers and suppliers will continue to be paid under the applicable Medicare payment methodology for covered services. In short, WISeR changes the approval step, not the fee schedule.
Prior Authorization Versus Prepayment Medical Review
| Feature | Prior Authorization | Prepayment Medical Review |
|---|---|---|
| When it happens | Before the service is delivered | After service, before payment |
| Main risk | Delayed scheduling and care | Delayed or denied payment |
| What you submit | Request with clinical documentation | Claim, with records on request |
| Best practice | Complete the request before booking | Keep records audit-ready at the point of care |
Missing documentation can delay scheduling under one path and reimbursement under the other. Either way, consistent clinical and administrative records are the common thread. Practices that already invest in improving their clean claim rate are better positioned for both.
How WISeR Can Affect Provider Revenue
The revenue effects are operational rather than abstract. Teams in affected states may see:
- Delayed procedures while requests are pending
- More administrative workload for each in-scope service
- Avoidable denials from incomplete or mismatched documentation
- Payment delays under prepayment review
- Staff time spent on follow-up
- Patient frustration when care is postponed
- Reduced visibility when cases live in inboxes and spreadsheets
Each of these shows up in familiar metrics such as days in A/R and net collections. See our guides to revenue cycle management KPIs and net collection rate to decide what to track. Results will vary by practice, service mix, and volume.
Common WISeR Readiness Gaps
- No centralized authorization owner
- Outdated code or service lists
- Incomplete documentation at submission
- Authorization status tracked in spreadsheets or inboxes
- No escalation process for additional-information requests
- Poor coordination among clinical, scheduling, and billing teams
- No tracking of turnaround times or non-affirmed decisions
- Confusion between Original Medicare and Medicare Advantage rules
Many of these are front-end problems. Our explanation of front-end versus back-end RCM shows why fixing intake and authorization upstream prevents costly rework later.
How Providers Can Prepare for CMS WISeR
- Create a WISeR applicability checklist covering state, coverage type, service, and codes.
- Build service-specific documentation templates so clinicians capture what reviewers need the first time.
- Assign ownership for every request, from submission to outcome.
- Track status, deadlines, and outcomes in a shared system.
- Establish an escalation workflow for additional-information requests and non-affirmed decisions.
- Train scheduling, clinical, and billing staff on the same process.
- Audit non-affirmed requests to find patterns. Our denial management strategies apply directly.
- Monitor CMS updates to the operational guide and service list.
- Consider specialized support if volume outgrows your team.
For a broader look at where authorization fits among other revenue risks, read how to reduce denials in medical billing and our overview of prior authorization versus precertification.
How PanaHealth Can Support Prior-Authorization Operations
PanaHealth supports provider teams with the administrative side of authorization. That can include:
- Coverage and requirement verification
- Documentation coordination with your clinical staff
- Authorization submission
- Status follow-up
- Escalation of requests that stall
- Case tracking and clear communication with your team
- Workflow reporting
- Capacity for higher-volume authorization periods
This support works alongside our medical billing services, revenue cycle management services, and denial management services, so authorization outcomes connect to claims and follow-up. For administrative capacity beyond billing, see our back office services. PanaHealth provides administrative and workflow support. We do not provide legal or clinical advice. We also cannot guarantee authorization or reimbursement outcomes.
Frequently Asked Questions
WISeR (Wasteful and Inappropriate Service Reduction) is a CMS Innovation Center model that tests technology-enabled prior authorization and prepayment medical review in Original Medicare for selected services.
Only in limited cases. WISeR applies to selected services in six states. Providers there can submit prior authorization requests or accept prepayment review. Outside the model, traditional Medicare rules for most services are unchanged.
Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
The model period began January 1, 2026 and runs through December 31, 2031. Submissions opened January 5, 2026, and applicable services began January 15, 2026. Verify against current CMS guidance.
A narrow set of outpatient services, such as certain nerve stimulation, pain injection, vertebral augmentation, skin substitute, and knee arthroscopy services. Use the current CMS operational guide for the authoritative code list.
It is a review of documentation after the service is delivered but before payment is released. Missing or weak records can delay or deny payment.
No. The model applies to Original Medicare beneficiaries only.
The provider can review the reason, supply additional documentation, resubmit, or follow the appeal options described in CMS guidance. Track every non-affirmed request so you can spot patterns.
Build an applicability checklist, standardize documentation, assign ownership, track outcomes, train staff, and monitor CMS updates.
Yes. Many practices delegate eligibility checks, documentation coordination, submissions, and follow-up to a specialized team while keeping clinical decisions in-house.
Is Your Team Prepared for the Additional Medicare Authorization Workload?
PanaHealth helps healthcare organizations manage eligibility checks, documentation coordination, submissions, follow-ups, and authorization tracking. Talk with our team about a scalable prior-authorization workflow for your organization.
