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The WISeR Model introduces defined steps for identifying eligible services, determining documentation requirements, submitting prior authorizations where applicable, and ensuring accurate claim submission. Although the scope of the model is limited, the operational requirements involve multiple data points and repeated documentation tasks.Automation can help organizations complete these tasks efficiently and consistently.

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Identifying WISeR eligible services

A service is subject to WISeR review only when specific conditions are met:

●     the CPT/HCPCS code appears onCMS’s WISeR list,

●     the diagnosis code aligns with applicable ICD-10 requirements,

●     the service is performed at an eligible site, and

●     it occurs in one of the participating states.

Automation can assist by evaluating these factors at the point of order and flagging services that fall within scope.This helps ensure that cases requiring WISeR workflows are identified early.

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Supporting documentation alignment with NCD/LCD criteria

Documentation for WISeR must meet the expectations outlined in the CMS manual. These expectations are based on existing NCDs and LCDs. Automated tools can compare available clinical documentation with the criteria used in review and surface missing or incomplete elements before submission. This supports accuracy for both optional prior authorization and prepayment review.

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Organizing documentation efficiently

Gathering clinical documents, such as imaging, operative notes, orders, and histories, can require manual effort across multiple systems. Automation can streamline this process by retrieving relevant files directly from the EHR and organizing them according to CMS’s documentation expectations for each service category.

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Assisting with submission and claim workflows

Electronic workflows can support several aspects of WISeR operations:

●     Submitting prior authorization requests to MACs or WISeR participants

●     Monitoring affirmation or non-affirmation decisions

●     Managing documentation requests during prepayment review

●     Ensuring Unique Tracking Numbers(UTNs) are captured and passed to billing for correct claim placement

Centralized visibility across these steps helps reduce process gaps or delays.

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Monitoring affirmation trends and process performance

Automation can also provide reporting on affirmation rates, documentation patterns, and turnaround times. These insights can help organizations evaluate whether their workflows are functioning as intended and identify opportunities for refinement. As CMS updates WISeR services or operational details, these tools can support ongoing alignment.

Automation is not a replacement for clinical judgment or coverage expertise, but it can help providers manage the structured requirements of the WISeR Model at scale and maintain consistency across ordering, documentation, and billing workflows.

Learn more at humatahealth.com