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WISeR Model

  • Writer: Amiee Coriano
    Amiee Coriano
  • Nov 15
  • 2 min read

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CMS released the names of the participants for the initial states set to start January 1,2025 and authorizations will be reviewed starting January 5, 2025. The participants are as follows:


Participant Name

MAC Jurisdiction

State 

 Cohere Health, Inc.

JH Novitas 

Texas 

 Genzeon Corporation

JH Novitas

New Jersey

 Humata Health, Inc.

JH Novitas

Oklahoma

 Innovaccer Inc.

J15 CGS

Ohio

 Virtix Health LLC

JF Noridian

Washington

 Zyter Inc.

JF Noridian 

Arizona

Noridian  - webinars starting December 2, 2025 for the PA process.

CGS- webinars start November 18,2025.


 

Authorization Information

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

    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.

If a provider who performs any services under the WISeR Model and opts out of the authorization process, the MACs have advised of the following process for the claims:


  • The MAC will suspend the claim and forward it to the model participant.

  • The model participant will send you an Additional Documentation Request (ADR) letter.

  • Send documentation to the model participant within the requested timeframe (maybe sooner than the standard 45-day window).

  • The MAC will process the claim based on the model participant's prepayment medical review decision.

Ways to Submit the requests

·       Individual MAC portal- the MAC will forward your information to the model participant. Within 2 business days, the model participant will send you a decision and Unique Tracking Number (UTN). Prior authorization decisions and associated UTNs are valid for 120 calendar days from the decision date.

·       Electronic Submission of Medical Documentation (esMD)- https://www.cms.gov/data-research/computer-data-systems/esmd/esmd-medicare-providers-and-suppliers

·       Submit a prior authorization request directly to the model participant technology company.

 
 
 

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