Supporting appropriate care through technology and clinical expertise

The WISeR Model is a CMS program designed to reduce wasteful, inappropriate, or low-value services by introducing enhanced prior authorization and medical review processes for selected procedures. The model evaluates whether services meet existing Medicare medical necessity criteria before payment or service delivery. The WISeR Model does not change existing Medicare coverage policies or payment rates but rather follows existing coverage criteria as outlined by the National and Local Coverage Determinations

The model applies only to beneficiaries enrolled in Original Medicare Parts A and B. It does not apply to Medicare Advantage plans.

The WISeR Model applies to select Medicare items and services identified by CMS. Providers should refer to the CMS WISeR Provider and Supplier Operational Guide for the current list of applicable services, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and operational guidance.

Zyter|TruCare is a CMS model participant responsible for performing prior authorization and medical review for procedures included in the WISeR model. Providers can submit requests through the Zyter|TruCare ProAuth provider portal, which supports the submission, tracking, and documentation of authorization requests.

Providers and suppliers may voluntarily submit prior authorization requests directly through the Zyter|TruCare ProAuth™ provider portal, which is the preferred electronic submission method.

Requests may also be submitted through the applicable Medicare Administrative Contractor (MAC), which forwards requests to the appropriate WISeR participant.

Providers who choose not to submit a prior authorization request may instead proceed through the post-service pre-payment medical review process under the WISeR Model.

Affirmed prior authorizations are valid for 120 days for the number of units requested.

Requests should include clinical documentation supporting medical necessity for the requested service. Examples may include:

• Provider clinical notes
• Imaging results
• Diagnostic testing
• Relevant patient history

Complete documentation at the time of submission can help support efficient review.

No. Artificial intelligence tools are used to help organize clinical information and support workflow efficiency. All coverage determinations are made by licensed clinicians applying Medicare coverage criteria.

WISeR participants issue determinations within three calendar days of receiving a complete standard prior authorization request. Requests submitted through a Medicare Administrative

Contractor (MAC) may require additional processing time before reaching the WISeR participant.

Questions regarding specific prior authorization requests, portal access, technical support, or request status should be sent to the Zyter|TruCare WISeR support team. General questions regarding the WISeR Model may also be directed to the CMS WISeR Model Help Desk.

A non-affirmed determination indicates that the submitted documentation did not demonstrate that the requested service met applicable Medicare coverage requirements. Providers and suppliers may submit additional supporting documentation through the resubmission process or pursue available appeal rights in accordance with applicable Medicare requirements.

Yes. Providers and suppliers may submit a resubmission with additional clinical documentation that supports medical necessity. When applicable, resubmissions should include the original Unique Tracking Number (UTN) to assist with processing.

Providers and suppliers who choose not to voluntarily submit a prior authorization request for a WISeR select item or service may have applicable claims reviewed through the post-service pre-payment medical review process. Medical review evaluates submitted documentation to determine whether services meet applicable Medicare coverage requirements before payment.

For detailed operational guidance, program documentation, and Medicare policy resources, providers may reference the following materials: 

• WISeR Provider/Supplier Guide: The best starting point for WISeR implementation details is the CMS Provider/Supplier Guide, which outlines the program requirements and operational processes.
• WISeR Program Overview: General information about WISeR.
• WISeR Provider Fact Sheet: A quick reference for providers outlining WISeR participation, program requirements, and key operational information.
• Medicare Administrative Contractor (MAC) website: Access Noridian's Medicare resources, operational updates, and provider guidance related to the WISeR model.
• WISeR Model listserv: Subscribe to the WISeR Model listserv to receive email updates on the program directly.
• Federal Register Notice: The official CMS notice establishing the WISeR model, including policy details and implementation information.
• WISeR program team: You can also reach out to the WISeR program team at WISeR@cms.hhs.gov with specific questions.