CMS WISeR Program
Zyter|TruCare will supply and maintain the prior authorization platform for the CMS WISeR program in Arizona. Because WISeR activities are administered regionally, CMS is advising providers to work directly with their Medicare Administrative Contractor (MAC), who will be the authoritative source for region-specific guidance and next steps to prepare for the go-live in January 2026. The MAC for Arizona, Noridian, can be contacted regarding WISeR at MAC@Noridian.com. Noridian plans to offer provider education sessions on WISeR through December 2025.
For your convenience, Zyter|TruCare will maintain this web page for ongoing WISeR education and updates. We will add new information as the model progresses – such as training materials, schedule of webinars or office hours, any changes in policy, and results from the model’s evaluations.
Staying engaged will ensure you have the latest information on the WISeR program. In addition, we encourage providers and other stakeholders to access these information sources:
- 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 Model listserv: Subscribe to the WISeR Model listserv to receive email updates on the program directly.
- WISeR@cms.hhs.gov: You can also reach out to the WISeR program team at WISeR@cms.hhs.gov with specific questions.
Contact Us
- Phone: +1 202.773.1430(Open 9 AM - 4 PM Local Arizona Time)
- Fax: +1 (667) 407-1889
- Email: wiser@zyter.com
Mailing Address
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Zyter Ethos
820 Armour Rd
PO Box 7351
Kansas City, MO 64116-9998
WISeR Model Overview
WISeR, which stands for Wasteful and Inappropriate Service Reduction, is a new model developed by the Centers for Medicare & Medicaid Services (CMS) Innovation Center. The WISeR Model is designed to reduce unnecessary medical services in Original Medicare (Part A and B) by ensuring that only clinically appropriate, “necessary” care is paid for.
This page provides an overview of WISeR for both healthcare providers/suppliers and Medicare beneficiaries – explaining what WISeR is, why it’s being implemented, how it works, and where to find additional resources and ongoing updates.
What is the WISeR model?
In simple terms, WISeR introduces an enhanced prior authorization process for select medical items and procedures that are prone to overuse or are of low value. The model will run for six years – from January 1, 2026, through December 31, 2031 – across six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
What is WISeR’s purpose?
Waste in healthcare is a major concern. In 2022, Medicare spent $5.8 billion on services that were determined to provide minimal clinical benefit. These procedures and tests drive up costs, but can also put patients at risk – for example, exposing them to complications (like infections or side effects from unwarranted procedures) and needless anxiety. The WISeR Model was introduced to identify and curb low-value care, ensuring that Medicare payments, as well as patients’ time and co-pays, go only toward treatments that are proven “reasonable and necessary” for the patient’s health.
How Does WISeR Work?
WISeR implements prior authorization for certain medical services before the service is performed. It focuses on a pre-selected set of medical services that have a history of overuse, fraud, or limited clinical benefit. Here’s a high-level look at how the model operates:
Technology-Assisted Review
Focus on Specific Services
No Change to Medicare Coverage
- WISeR pairs CMS with third-party technology vendors (private companies specializing in technology-supported prior authorization processsing) to streamline the prior authorization request process. When a Medicare provider wishes to perform or order one of the WISeR-targeted services, the request is processed using these vendors’ tools, with the oversight of clinical staff, to determine if the requested service meets Medicare’s coverage criteria. If a claim for these services is sent without prior authorization, then a determination of whether coverage criteria are met is made prior to processing the claim.
- Artificial intelligence (AI) is used to expedite the review process, in order to get to a faster or immediate approval, when appropriate. However, only a human clinician will confirm any decision to deny a requested authorization.
- For example, WISeR will review requests for services like skin and tissue substitutes (grafts), implantation of electrical nerve stimulators, and knee arthroscopy for osteoarthritis, among others. These are treatments that can be very helpful in the right situations but are often been used in cases where they may not help (or could even harm) the patient.
- Importantly, emergency services and strictly inpatient hospital procedures are excluded from WISeR – the model will not delay true emergencies or urgent inpatient care. All recommendations for non-affirmation under WISeR are reviewed by appropriately licensed clinicians using standardized, evidence-based guidelines, to ensure that necessary care is not wrongly denied.
- WISeR does not change any Medicare benefits or coverage policies. The Medicare rules for what’s covered remain the same – WISeR is simply a tool to enforce those rules more proactively for certain services. Health care coverage for Medicare beneficiaries will not change under this model.
- Payment rates to providers and suppliers for services are not changed by WISeR. Also, WISeR only affects Original Medicare fee-for-service, so Medicare Advantage enrollees are not impacted by this model.
What does WISeR mean for providers & suppliers?
If you are a Medicare-enrolled provider or supplier in one of the six WISeR states, and you furnish any of the selected WISeR services for Original Medicare patients, the model applies to your organization. Beginning January 5, 2026, those specific services will require either a prior authorization approval before you deliver the service, or they will undergo a pre-payment medical review if you submit the claim without prior authorization.
As a provider, you have two options to comply with WISeR’s requirements when ordering or scheduling a targeted service:
- Submit a Prior Authorization Request (Pre-Service Approval): You can request approval before performing or ordering the WISeR-covered item or service. This involves sending a prior authorization request with supporting medical documentation. You may submit the request to your usual Medicare Administrative Contractor (MAC), who will forward it to the WISeR reviewer. You may also send the request directly to the WISeR program’s technology partner for your state (for Arizona, this is Zyter|TruCare).
- Your request needs to include required data elements (patient info, provider info, and justification documents) showing that the service meets Medicare’s coverage criteria for medical necessity.
- Once submitted, the WISeR reviewer will issue a provisional determination – either affirmation (approval) or non-affirmation (denial) – usually within a few days.
- If the request comes back non-affirmed (denied), you can choose not to provide the service or, if you disagree, you can gather additional evidence and resubmit for reconsideration.
- Proceed Without Prior Auth (Post-Service Review): Alternatively, you might decide not to seek prior authorization. In this case, you would provide the service to the patient as you normally would and then submit the claim to Medicare afterward. However, the Medicare MAC will flag that claim (since no prior authorization request is on file) and send it for pre-payment medical review under WISeR.
- The WISeR reviewer (technology partner and their clinical staff) will likely reach out to you for the patient’s medical records and any documentation to support that the service was medically necessary. They will review the claim against Medicare’s coverage rules just as they would in a prior auth. If the service is found to meet requirements, the claim will be paid. If it does not meet Medicare’s criteria, the claim will be denied (i.e., not paid by Medicare).
- This post-service review pathway essentially acts as a safety net to catch any potentially inappropriate claims that didn’t go through the upfront authorization.
In either scenario, the goal is to ensure that the service meets Medicare’s “reasonable and necessary” standards before Medicare pays the claim.
CMS has indicated that it will monitor the process closely and even plans to offer a “Gold Card” exemption in the future – meaning that providers and suppliers who establish a consistent track record of compliance (i.e., their requests nearly always meet the criteria) could be exempted from WISeR prior authorization requirements for those services. This potential Gold Card policy would reduce administrative burden on providers for whom the vast majority of requests are approved, allowing them to bypass prior authorization. (Details on this exemption are expected to be released as the model progresses.)