Announcements

CMS will launch the WISeR Model on January 1, 2026; a Medicare pilot program focused on establishing a consistent process for reviewing certain elective, high-cost outpatient services. To guide participating providers, CMS released a 61-page provider manual detailing operational requirements, workflows, timelines, and documentation standards.The model does not introduce new coverage rules; it applies existing NationalCoverage Determinations (NCDs) and Local Coverage Determinations (LCDs) through a more structured review process.

Scope of the Model

WISeR applies only to traditional Medicare beneficiaries receiving specific services in one of six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

To fall within WISeR’s scope, a service must meet all of the following conditions:

●     It matches a CPT/HCPCS code included in CMS’s WISeR appendix

●     It includes one of the requiredICD-10 clinical indications

●     It occurs in an eligible place of service, such as a hospital outpatient department or ASC

●     It is performed in a participating state

Because eligibility depends on multiple factors, organizations may need reliable methods to flag WISeR-applicable cases at the time of order.

Operational Pathways

CMS provides two pathways for compliance:

1. Optional Prior Authorization
   ‍Providers may submit a prior authorization     request before delivering the service. If affirmed, CMS issues a Unique     Tracking Number (UTN) that must accompany the claim.
   
2. Prepayment Medical Review
   ‍Providers may choose not to submit prior authorization. In that case, the claim will be held for review, and documentation may be requested. Providers must respond to requests within 45 days.    

Both pathways are permissible, and the decision determines how documentation and review activities are handled.

Key Dates

●     January 1, 2026: WISeR program begins

●     January 5, 2026: First date CMS accepts optional prior authorization requests

●     January 15, 2026: First date services can be performed under WISeR

Why WISeR Was Developed

CMS structured WISeR to support a more consistent review process for services where utilization, cost, or documentation variability is common. The model uses existing Medicare criteria and incorporates defined service lists, documentation expectations, and standardized review timeframes. CMS will use the pilot to observe provider participation, documentation trends, and operational workflows.

What Providers Should Focus on Now

Organizations preparing for WISeR will need to understand:

●     Which services, diagnoses, and sites are included

●     How to identify WISeR cases at order entry

●     What documentation is required under the NCD/LCD criteria

●     How to manage UTNs and incorporate them into claim workflows

●     How to meet response timelines for documentation requests

Next: the foundational elements will shape the operational workflows.

Learn more at humatahealth.com