CMS WISeR Program
Supporting Appropriate Care Through Technology and Clinical Expertise
The Wasteful and Inappropriate Service Reduction (WISeR) Model is a Centers for Medicare & Medicaid Services (CMS) program designed to help ensure certain Medicare services meet established medical necessity criteria before payment or service delivery. The model uses prior authorization and medical review, supported by technology and clinician oversight, to promote appropriate utilization while maintaining access to medically necessary care. Zyter|TruCare is a CMS-selected WISeR participant and provides the Zyter|TruCare ProAuth™ provider portal, which enables providers to submit and manage prior authorization requests electronically. The platform enables providers to:
- Submit prior authorization requests electronically
- Track authorization status and determination letters
- Upload supporting documentation
- Manage multiple NPIs and users within a single account
To Login or Register:
For Arizona providers, Zyter|TruCare supplies and maintains the prior authorization platform used in the WISeR program. Because WISeR activities are administered regionally, CMS advises providers to work with their Medicare Administrative Contractor (MAC) for state-specific guidance. Arizona providers can contact Noridian at MAC@Noridian.com for additional information.
For assistance with registration, portal access, technical issues, or for general question regarding the WISeR program, please contact:
Zyter|TruCare WISeR Support
- Phone: +1 (202) 773-1430 (open 9 AM – 4 PM local Arizona time)
- Email: wiser@zyter.com
Frequently Asked Questions
What is the WISeR Pilot Program?
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. WISeR does not change Medicare coverage rules.
Which patients are included in the WISeR model?
The model applies only to beneficiaries enrolled in Original Medicare Parts A and B. It does not apply to Medicare Advantage plans.
What is Zyter’s role in the WISeR program?
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.
How do providers submit a prior authorization request?
Providers may submit prior authorization requests through the Zyter|TruCare ProAuth provider portal, which is the preferred submission method. Requests may also be submitted through the Medicare Administrative Contractor (MAC), if needed.
How long are approved authorizations valid?
Affirmed prior authorizations are valid for 120 days for the number of units requested.
What documentation should be included with a request?
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.
Are authorization decisions made by artificial intelligence?
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.
Additional Program Resources
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 Model listserv: Subscribe to the WISeR Model listserv to receive email updates on the program directly.
- WISeR program team: You can also reach out to the WISeR program team at WISeR@cms.hhs.gov with specific questions.
Need Help?
For questions related to:
- Zyter|TruCare ProAuth™ portal access
- Prior authorization submissions
- Technical support
- WISeR request status
Contact:
Zyter|TruCare WISeR Support
- Phone: +1 (202) 773-1430 (open 9 AM – 4 PM local Arizona time)
- Email: wiser@zyter.com
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
-
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.)