WISeR Model Q&As
CGS captured the questions and answers below during our webinars on 11.18.2025 and 12.17.2025.
Please note: CPT, HCPCS, and ICD-10 codes will be maintained throughout the duration of the WISeR Model and could be subject to change. Any updates would be included in a future version of the WISeR Model Provider and Supplier Operational Guide.
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General
- What is the difference between a Prior Authorization Demonstration and the WISeR model?
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Prior authorization demonstrations typically follow the same guidelines and processes as other established CMS prior authorization programs. The WISeR Model introduces new processes such as the use of a Model Participant to leverage enhanced technologies such as Artificial Intelligence (AI). Please refer to Figure 1
for the WISeR Model Workflow.
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- We are seeing several start dates for the WISeR Model. We are seeing start dates of Jan 1st, Jan 5th and Jan 15th of 2026. Does this mean that Jan 1 the prior field opens but it is not required until 1/15/26?
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CMS will implement the WISeR Model on January 1, 2026. Beginning on January 5, 2026, CGS will accept WISeR prior authorization requests for dates of service on or after January 15, 2026.
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- I thought I read that the start date was delayed until Feb 15, 2026.
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There are multiple prior authorization programs. The Prior Authorization Ambulatory Surgical Center (ASC) Demonstration is delayed until February 16, 2026. This demonstration is separate from the WISeR Model Prior Authorization. Beginning on February 2, 2026, Ohio ASCs can submit prior authorization requests for dates of service on or after February 16, 2026.
Please see our website for more information on the Prior Authorization ASC Demonstration. The WISeR Model, beginning for services provided on January 15, 2026, and after, also applies to ASCs, HOPDs, and services provided in the beneficiary's home or physician's office.
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- What is the duration that these prior authorizations will be necessary?
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The WISeR Model will run for 6 performance years (January 1, 2026 – December 31, 2031).
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- Can you confirm whether WISeR is determined by the state where the service is performed rather than the provider location (bordering state, KY)?
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The WISeR Model, for CGS J15, applies to services provided in Ohio rather than the provider's location.
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- Testing can be done in December, what is the process for this?
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Testing procedures and implementation support questions should be directed to WISeR@cms.hhs.gov. Currently, CMS has not provided a dedicated pre-launch testing period provided for providers. Providers should prepare systems and staff training in advance of the January 5, 2026, Go-Live date to ensure a smooth transition to WISeR prior authorization requirements.
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- How will Innovaccer be informed when local coverage determinations (LCDs)/national coverage determinations (NCDs) change so that they can adjust their acceptance criteria?
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CMS will notify the WISeR participant (Innovaccer) of any upcoming NCD or LCD changes. In addition, the WISeR participant (Innovaccer) will monitor the Medicare Coverage Database and is registered to receive update alerts. The WISeR participant (Innovaccer) will make any necessary system adjustments prior to the change effective date.
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- Will a provider portal guide be released for the Innovaccer portal? Also do we know when the portal URL will be available and when we can start registering on the Innovaccer portal?
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The Innovaccer WISeR Portal will not be ready on January 5, 2026. It is planned to be launched at a later date in Q1 of 2026. Prior to its launch, Innovaccer will notify the provider community of its anticipated launch date and the steps associated with registering to use the Innovaccer WISeR Portal. Innovaccer also plans to provide educational resources to providers in the form of a guide and webinars prior to its launch.
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Place of Service
Selected Items & Services
- Only Epidural steroid injections require authorizations in pain management? How about RFA or SI joint injections?
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Only epidural steroid injections for pain management are on the WISeR prior authorization list for pain procedures at this time; radiofrequency ablation (RFA) and sacroiliac (SI) joint injections are not WISeR selected services. Please refer to Appendix A of the WISeR Provider and Supplier Operational Guide for a current list of the WISeR Select Items and Services.
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- PMR/ Neuroscience Dept here – usually with the facet joint injection authorizations on the portal- when requesting, we would initially have to enter the start date/DOS requested 10 days out. Would it only be 3 days now? For instance, count 3 business days out from today for requested start date?
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Facet joint injections (facet joint interventions for pain management) are explicitly included in the national Hospital Outpatient Department (HOPD) Prior Authorization Demonstration and are not currently included in the WISeR Model. The HOPD prior authorization program timeframe has not changed.
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- Will this affect spinal injections done IN OFFICE?
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Yes, the WISeR Model applies to spinal injections provided in a physician's office.
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- The use of skin/tissue substitutes lists specifically lower extremity chronic non-healing wound/lower extremities. Will the WISeR model include use of skin/tissue substitutes for wounds/ulcers of different etiologies (i.e., abdominal wounds, burns on arms, scalp ulcers, etc.)?
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Please review the WISeR Model Provider and Supplier Operational Guide
for specific HCPCS/CPT codes subject to WISeR prior authorization or prepayment medical review under the WISeR Model.
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- I hope to better understand the process for obtaining an authorization for skin substitutes and what guidelines will be followed for both a provider and hospital outpatient wound facility?
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To obtain authorization, providers or facilities must submit a request to their Medicare Administrative Contractor (MAC) that includes complete medical documentation: patient diagnosis and history, wound measurements and progress notes, evidence of conservative therapy attempted, and the physician's order with product details (HCPCS/CPT codes, units, and site of service). Requests are reviewed against WISeR program criteria, NCD, LCDs, and correct coding and billing rules. Once affirmed, the prior authorization Unique Tracking Number (UTN) must be included on the claim, and the service furnished exactly as approved. If the WISeR prior authorization is not obtained, prior to the service being billed it will be subject to prepay medical review.
The process is the same for both individual providers and hospital outpatient wound facilities. For full details, please see the WISeR Model Provider and Supplier Operational Guide
. This information applies to providers and facilities. Sections 3 & 4 outline the prior authorization request and review processes. Section 6.2.14 describes program specifics for skin substitutes.
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- As of today, there are new LCDs for Skin Substitutes scheduled to become effective on January 1, 2026. On 1/1/2026, if the new LCDs are effective. Will the AI screening use the criteria from the current LCD or the LCD effective 1/1/2026?
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The LCD for Skin Substitutes (L39756), scheduled to become effective on 1/1/2026, is withdrawn. Please see the WISeR Model Provider and Supplier Operational Guide
(Section 6.2.13) (as of December 23, 2025) for updated guidance. Accordingly, Innovaccer will regularly update their platform to account for the NCD or LCD that is effective at the time of the medical necessity review.
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- The CPT code 64561 is used to bill for the Sacral Nerve stimulator trial and for the permanent implant. Per the Operational Guide, only the permanent implant needs authorization, NOT the trial, but this other publication states both the trial (PNE) and the permanent implant needs prior authorization? Do we need to prior authorize the trial and permanent implant?
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The WISeR prior authorization is for the HCPC. If the same HCPC is utilized and only either the trial or permanent is part of the program, documentation needs to be very detailed.
Please see the WISeR Model Provider and Supplier Operational Guide
for guidance on which implant is reviewed under the WISeR Model.
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- Last month CPT 15823 and 67904 were on the list. They are not listed today. Can you confirm that in the last month these have been removed?
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CPT 15823 and 67904 are not codes that are included in WISeR. These codes are, however, included in the Ambulatory Surgical Center (ASC) prior authorization demonstration that is currently delayed until February 16, 2026, and the Hospital Outpatient Department services demonstration.
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- There was an appendix B added to the WISeR associated codes list in the WISeR Operational Guide that does contain some different than Appendix A shown. Do these also require authorization starting 1/5/26 for DOS 1/15/26 and after? Specifically, 29880 29881.
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Codes in the Appendix A are subject to WISeR prior authorization. For codes in Appendix B (associated services), claims related to or associated with a WISeR select item or service will not be paid if the WISeR select item or service is non-affirmed during WISeR prior authorization or denied payment during claims processing. Please refer to Section 7.3 of the WISeR Provider and Supplier Operational Guide for information about payment for associated services.
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- How do providers submit data for the 6-month post implant symptom relief reporting?
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As the trial doesn't require prior authorization, the documentation you submit with your prior authorization request or in response to an ADR should include a baseline pain scale prior to placement of trial, the current level of pain using the same pain scale, and an overall encompassing statement of the success of the trial in dealing with the pain and function.
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- What specific documentation is needed for actual implanted devices (HCPCS codes C1761 for implantable neurostimulator electrode, C1894 for introducer/sheath)?
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Currently, HCPCS codes C1791 and C1894 aren't listed in the WISeR Model Provider and Supplier Operational Guide (Appendix A) and, therefore, aren't included in the WISeR Model. Since HCPCS code C1894 is listed in Appendix B, please see Section 7.3 for information about payment for associated services.
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- The code 11042 is not listed in either LCD L35041 or L36690, but it appears in the guide. Please advise if this code would require prior authorization, or if this is an error?
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HCPCS code 11042 isn't listed in the WISeR Model Provider and Supplier Operational Guide (Appendix A); however, it does appear in Appendix B. Please see Section 7.3 for information about payment for associated services.
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- Is the list of CPT/HCPCS included in the operations manual finalized? This is a substantial list, so we wanted to confirm.
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Yes, the current list is in the WISeR Model Provider & Supplier Operational Guide, last updated on November 6, 2025, however, CMS has indicated that there may be adjustments to this list throughout the performance period and will notify Participants, the MAC, and providers/suppliers accordingly.
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- Question on 62323. The documentation indicates this will require a PA for steroid injections, but it can also be used for pain medications. Will both scenarios require prior authorization, or will it be medication specific?
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CPT code 62323 is listed in the WISeR Model Provider and Supplier Operational Guide (Appendix A) and is, therefore, subject to the WISeR Model prior authorization or prepayment medical review process regardless of whether the injected substance is a steroid or another pain medication. WISeR applies to the service code itself rather than to the specific drugs.
LCDs and their related billing and coding articles for Epidural Steroid Injections for Pain Management (L39015, L39240, and L36920) determine coverage and medical necessity criteria. Please reference these policies for the most current clinical and documentation requirements.
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- Regarding Electrical Nerve Stimulators, I see CPT 63655 (Laminectomy) was listed on a previous slide, but the placement CPT 63685 was not listed. Is that correct?
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CPT 63655 is included in the WISeR Provider and Supplier Operational Guide in Appendix A (WISeR Select Items and Services). CPT 63685 is in Appendix B (WISeR Associated Codes List) of the WISeR Provider and Supplier Operational Guide. Please refer to Section 7.3 (Payment for Associated Items Services) of the WISeR Provider and Supplier Operational Guide for more information regarding claims related to or associated with a WISeR select item or service. In summary, claims related to or associated with a WISeR select item or service will not be paid if the WISeR select item or service (From Appendix A) is non-affirmed during prior authorization or denied payment during claims processing.
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- Do the codes for anesthesia, devices, drugs, x-rays need to be included with the authorization request? Also do drug codes need to be included with injections?
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Prior authorization only applies to the items and services identified in the WISeR Model Provider and Supplier Guide (Appendix A). Determine if the HCPCS/CPT code for a planned service is listed. If so, you have the option to:
- Submit a prior authorization request before you render the service.
- Submit a claim after you render the service knowing that it's subject to prepayment medical review (to determine medical necessity using applicable Medicare coverage policies such as any relevant NCDs or LCDs).
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- With MBB's and radiofrequency ablation there are a few clinical questions to answer, will there be any clinical questions to answer or just the form and uploading documents?
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Medical branch blocks (MBB) and radiofrequency ablation (RFA) are no longer on the list based on the most recent update. As codes are subject to change, we encourage providers and suppliers to regularly review the WISeR Provider and Supplier Operational Guide.
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- So, do CPT 29881 and 29880 require authorization or if submitted with 29877 we need to have authorization for 29877 before they will pay?
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CPT codes 29881 and 29880 (Appendix B) aren't subject to the WISeR prior authorization and medical review process. If CPT codes 29881 and 29880 (Appendix B) are submitted with CPT code 29877 (Appendix A), CPT codes 29881 and 29880 (Appendix B) will not be paid if CPT code 29877 (Appendix A) is non-affirmed during prior authorization or denied payment during claims processing. See the WISeR Provider and Supplier Operational Guide Section 7.3.
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- Will there be somewhere precert teams can do a CPT code lookup if unsure?
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Please review Appendix A in the WISeR Model Provider and Supplier Operational Guide for specific HCPCS/CPT codes subject to WISeR prior authorization or prepayment medical review under the WISeR Model. As codes are subject to change, we encourage providers and suppliers to regularly review this resource.
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Prior Authorization
- What do we do for patients that require authorizations as of January 1st?
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The WISeR Model prior authorization requirements apply to services provided on and after January 15, 2026. For services furnished before that date, providers and hospital outpatient wound facilities should continue to follow the existing Medicare coverage and billing rules in place. This means that claims for services provided between January 1 and January 14, 2026, will be processed under the standard Medicare rules applicable at that time, without WISeR prior authorization.
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- How do we send Prior Authorization requests directly to Innovaccer?
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Beginning on January 5, 2026, you may submit prior authorization requests to CGS via mail, fax, or myCGS portal. CGS will forward your request to Innovaccer. You can also submit directly to the WISeR participant (Innovaccer) via esMD
(Electronic Submission of Medical Documentation). The WISeR participant (Innovaccer) will be releasing a provider portal at a later date in Q1 2026.We'll update our website when additional submission methods become available.
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- The PAR 457 Form is only needed if prior authorization is being requested by fax or mail and is not needed when using the portal?
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Correct. Please complete the PAR 457 Form when submitting the WISeR prior authorizations via fax or mail. There will be a form that mirrors the PAR 457 available within the portal to complete for portal submissions.
The PAR 457 Form is accessible from the following resources:
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- I read that we are going to be able to use Cohere for the Prior authorizations? Is that correct?
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CMS assigned six different vendors to be Participants in six different MAC jurisdictions. Innovaccer is the WISeR Model Participant for J15 CGS (Ohio). Cohere is the WISeR Model Participant for JH Novitas (Texas). Cohere is not applicable to J15 CGS (Ohio).
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- Is it true that organizations have to opt in to have prior authorizations required? If so, how do we opt in?
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No, there's no process to opt in. The WISeR prior authorization or medical review process applies to any WISeR service provided in an Ohio hospital outpatient department (HOPD), ambulatory surgical center (ASC), physician office, or beneficiary home setting. It is optional for the provider or supplier to submit a prior authorization. If a provider or supplier opts to NOT submit a prior authorization and render service, their claim will be subject to a prepayment claim review process for medical necessity review.
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- If the determination from the WISeR prior authorization submission returns as "non affirmed", will the provider be able to submit an appeal? If so, which platform will this be done on?
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If an initial prior authorization request is non-affirmed, you may submit a subsequent request (resubmission) with additional or updated documentation to correct an error or omission identified during the initial review. The number of resubmissions is unlimited.
If you submit a claim with a UTN associated with a non-affirmed decision, it will deny. Such claim denials constitute an initial claim determination and are subject to the existing Medicare appeals process.
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- If we utilize fax submissions, will this affect turnaround timeframes for determinations? How will we receive confirmation that the participant received the request?
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A fax submission would not alter the timeframe. The review timeframe for fax submissions is the same as other submission methods. Innovaccer will make a determination within 3 days of receiving an initial or resubmission request or within 2 days of receiving an expedited request. Innovaccer will then request a UTN from CGS. This process may add 1-2 days before you receive a fax response (decision letter) from Innovaccer.
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- I've seen two names used: "provisional affirmation" and "affirmation", is there a difference between both?
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Both terms "Provisional Affirmation" and "Affirmation" indicate that a future claim likely meets Medicare's coverage criteria, including coding and payment rules.
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- If a prior auth is not completed how long does this review take for determination?
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Innovaccer has 3 calendar days to complete a medical necessity review for prior authorization request. Once that review is completed, the determination is communicated to CGS. CGS will then provide Innovaccer with the UTN, which can take 1-2 days. Once Innovaccer has the generated UTN, they will send the determination letter to the provider in the same manner in which it was submitted by the provider. Expedited requests are processed by Innovaccer within 2 calendar days with the same additional time to obtain the UTN and send the determination letter. Please see Question 7 for more information on the expected timeframes for claims without an affirmed UTN.
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- Will Healthcare Entities acting on behalf of patients+providers be able to submit PAs to Innovaccer and will Innovaccer respond directly to the Healthcare Entity requestor with the results of the PA? Will a practice be permitted to give their EHR or billing company access to the Innovaccer portal once it becomes available next year? Can a vendor submit authorizations on behalf of a provider?
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Healthcare entities (such as revenue cycle vendors, billing companies, and other third-party firms) can submit WISeR prior authorization requests on behalf of a Medicare-enrolled provider, and Innovaccer will issue the determination back to whoever submitted the request using the same channel.
Who can submit WISeR PAs
- CMS frames WISeR submissions in terms of "requesters" and allows prior authorization requests to be sent by or on behalf of WISeR providers/suppliers via fax, esMD, mail, or electronic portals (CGS-specific or Innovaccer–specific).
- Innovaccer will review the request and send the prior authorization determination (with the UTN) back to the requester using the same method that was used to submit the PAR.
Innovaccer portal and vendor access
- In Ohio, CMS specifies that all WISeR prior authorization requests may be submitted either through CGS (including myCGS/esMD) or directly through the Innovaccer WISeR portal once available.
- CMS and Innovaccer do not prohibit practices from authorizing third parties (e.g., an EHR vendor, billing company, or other healthcare entity) to access the Innovaccer portal or submit PARs on their behalf, so long as the provider has granted appropriate authorization and any required portal registration, user agreements, and HIPAA/business-associate requirements are met.
Practical implications for your question
- Yes, a healthcare entity acting on behalf of patients and providers can submit WISeR prior authorizations to Innovaccer (directly or via CGS), and Innovaccer will send the PA decision back to that submitting entity.
- Yes, a practice may give its EHR vendor or billing company access to the Innovaccer WISeR portal once it is live, provided the practice controls and documents that access under standard HIPAA/BAA and portal-credential rules.
- In operational terms, a vendor can submit authorizations on behalf of a provider under WISeR, but the provider remains responsible for compliance with Medicare requirements and for ensuring that only authorized agents use the portal credentials tied to the practice.
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- Will submitting to the Innovaccer WISeR Portal be faster than using the myCGS portal?
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The required turnaround times for performing medical necessity reviews are the same whether it is submitted via the myCGS Portal or the Innovaccer WISeR Portal. However, once the Innovaccer WISeR Portal is launched in Q1 2026, it is anticipated that the Innovaccer WISeR Portal will provide more tools for the provider to track the status of a prior authorization request. Additionally, Innovaccer plans to enhance the portal experience so that a provider can upload a prior authorization request and do a "pre-check" which will notify the provider of any items that might result in either a dismissal or non-affirmation prior to the provider submitting the request so that the provider is able to resolve that issue prior to the official submission. This should provide more near real-time visibility into whether a request will be affirmed or not affirmed based on the documentation that is uploaded.
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- Is there an option to submit an auth request after the service but before the claim is submitted? For example, if we realize the day after the service was provided that it required PA, but we have not submitted the claim yet, can we request auth through the normal method? Or does this situation become a retro auth situation and we have to submit the claim and await the ADR?
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Retroactive UTNs will not be supplied. The authorization should be requested prior to the service being rendered. Since the UTN that is assigned to PAR is based upon the determination date up to 120 days, the UTN would not be valid for a past date of service. Therefore, the provider will need to submit the claim and go through the ADR process for payment determination.
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Prepayment Medical Review
Claims
Education
- Will Innovaccer be doing any provider outreach? They are not a vendor that currently performs any type of audit.
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Yes. In addition to participating in CGS-sponsored and other collaborative events, The WISeR participant (Innovaccer) will publish a schedule of events on their website
. Innovaccer is partnering with KFMC Health Improvement Partners to perform the medical necessity reviews for WISeR authorization requests and claims that may be non-affirmed or denied.
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- Where can providers access the training modules? And is that for office pre-certification staff or the providers themselves?
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To access the CMS Provider Office Hour video and slides referenced during this event, please see WISeR Model | CMS
(Additional Information). These resources are available to the public, including providers and staff.For future CGS-sponsored events, please visit the Part A or Part B Calendar of Events. Innovaccer will also publish a schedule of events on their website
.
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- Where will we check for updates to the process? Will they be communicated to facilities or do we have to seek out the updates?
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We'll update our websites when new information is available.
You may also subscribe to our electronic mailing lists:
- CGS
- WISeR Model
- Innovaccer: Please email ohcmswiser-inquiry@innovaccer.com to be added to their distribution list.
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Updated: 12.31.2025
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