License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
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The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

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Wasteful and Inappropriate Service Reduction (WISeR) Model

The WISeR Model Prior Authorization and Medical Review Process leverages enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and appropriate Medicare payment for a select set of items and services that are vulnerable to fraud, waste, and abuse.

Timeframe

January 1, 2026 – December 31, 2031

Services

The WISeR Model includes certain services provided in:

Ohio (New Jersey, Oklahoma, Texas, Arizona, and Washington)
Hospital Outpatient Departments (HOPDs)
Ambulatory Surgical Centers (ASCs)
Physician's office
Beneficiary's home

See the WISeR Model Provider and Supplier Operational Guide:

Appendix A – WISeR Select Items and Services
Appendix B – WISeR Associated Codes List
Appendix C – ICD-10 Indications for Relevant WISeR Items and Services

Claim exclusions:

Veterans' Affairs
Indian Health Services
Medicare Advantage (including IME only claims)
Part A/B rebilling
Emergency Department services (revenue code 045X or modifier ET)

Model Participants

Innovaccer, the model participant technology company assigned to Ohio, will:

Process prior authorization requests and issue affirmation or denial decisions.
Perform prepayment medical review for model service claims submitted without prior authorization.

Process

The WISeR Model is voluntary and doesn't change existing Medicare coverage or payment policy.

For services included in the model, choose one of the following options:

Submit a prior authorization request before you render the service.
Render the service and submit a claim without prior authorization. CGS will suspend the claim and forward it to Innovaccer for prepayment medical review.

Prior Authorization

Beginning on January 5, 2026, you may submit prior authorization requests for dates of service on or after January 15, 2026.

Complete the WISeR Model Prior Authorization (PAR 457) form and choose one of the following submission methods:
- Submit prior authorization requests to CGS; CGS will forward the request to Innovaccer:
  - myCGS portal
  - Fax: 615.660.5300
  - Mail: PO Box 20203, Nashville, TN 37202
- Submit prior authorization requests directly to Innovacer:
  - Electronic Submission of Medical Documentation (esMD)
  - Innovaccer WISeR portal (coming soon)
Innovaccer will send you a decision and Unique Tracking Number (UTN).
Prior authorization decisions and associated UTNs are valid for 120 calendar days from the decision date.
For each prior authorization request, providers are allowed an unlimited number of resubmissions (subsequent request after receiving a non-affirmed decision).

Please visit the Innovaccer website for additional details.

Prepayment Medical Review

For WISeR service claims submitted without prior authorization:

CGS will suspend the claim and forward it to Innovaccer.
Innovaccer will send you an Additional Documentation Request (ADR) letter.
Send documentation to Innovaccer within 45 days.
CGS will process the claim based on Innovaccer's prepayment medical review decision.