WISeR model: what an orthopedic practice's admin team should check
The WISeR model is a CMS Innovation Center test that adds prior authorization review for selected Original Medicare items and services in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It runs from January 1, 2026 to December 31, 2031, and it does not apply to Medicare Advantage (CMS WISeR model page, as of October 19, 2026).
This page covers operations only: who reviews requests, how fast, and what to put in your workflow. It is not clinical, coding or legal advice, and it does not tell you what to do for any patient or claim.
Who runs WISeR in each state
CMS selected six technology companies, one per state. Each one handles prior authorization requests for Original Medicare in its state. CMS requires participants to have clinicians, and says a human clinician must review every non-affirmation (CMS WISeR FAQ).
| State | Model participant |
|---|---|
| Arizona | Zyter Inc. |
| New Jersey | Genzeon Corporation |
| Ohio | Innovaccer Inc. |
| Oklahoma | Humata Health, Inc. |
| Texas | Cohere Health, Inc. |
| Washington | Virtix Health LLC |
Source: CMS, WISeR Model page and WISeR Model Provider Factsheet (as of October 19, 2026).
What is covered
CMS describes the model as covering “a pre-selected set of services” it considers vulnerable to fraud, waste and abuse. The CMS model page names three examples: skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. The full list, with codes, is in Appendices A to C of the WISeR Provider and Supplier Operational Guide. Check your own service lines against those appendices; this page does not list codes.
Your two options
CMS’s model page says providers can submit a prior authorization request or go through a post-service, pre-payment review. If you do not submit a request for an included service, the claim is subject to medical review before payment. CMS also states that payment to providers does not change under the model (model page) and that appeal rights are preserved (CMS WISeR FAQ).
Requests can go directly to the model participant, or through your MAC, which forwards them to the participant.
How long decisions take
| Request type | Stated timeframe | Source |
|---|---|---|
| Standard | Typically a determination within 3 days of receiving the request | CMS WISeR FAQ |
| Expedited | Within 2 days, if the participant confirms that delay could seriously jeopardize the patient’s life or health | CMS WISeR FAQ |
| Portal requests | The 72-hour turnaround for requests sent to a participant’s portal applies starting January 5, 2026, for dates of service on or after January 15, 2026 | CMS WISeR FAQ |
Gold carding
CMS’s model page says providers and suppliers with compliance records “may be exempt from the WISeR review process in the future.” The CMS FAQ calls this a “gold carding” or exemption program and says CMS was planning to launch it in 2026, with providers who consistently meet criteria generally exempt from additional prior authorization and pre-payment review (FAQ as of its 09/22/2026 modification). CMS publishes an Exemption Program Provider Factsheet; check it and the model page for the current status and criteria.
What an administrator can check this month
These are workflow questions, not billing advice.
- Is your group in a WISeR state? A group with several locations may span more than one state. List locations by state and by MAC.
- Who owns WISeR requests? Name one person per location for submissions, and one for tracking outcomes.
- Where do requests go? Decide whether you submit through the participant’s portal or through your MAC, and write down the contact path for each state’s participant.
- Do you measure turnaround? Compare actual decision times with the 3-day and 2-day figures above. Without a log, you cannot tell a slow participant from a slow internal handoff.
- What happens to a request that is not approved first time? CMS says clinicians review those. Decide who gathers the additional documentation and where its status lives.
- Which of your service lines are on the list? Match them against Appendices A to C once, and keep the result in a shared sheet that the scheduling team can see.
Where software fits
Spreadsheets and email threads hold up with one payer in one state. They strain when each state has a different participant, a different MAC and a different portal. A small internal tool that records each request, its owner and its turnaround time is one way to start.
More on the work behind a request is in prior authorization software for orthopedic and spine practices. Umakes builds custom internal software for healthcare organizations. The client owns it, and it runs in the client’s own Google Cloud project. If you want a second opinion on where your prior authorization workflow loses time, the first step is a free 30-minute workflow audit.
Questions
Does WISeR apply to Medicare Advantage? No. CMS states that WISeR does not apply to people with Medicare Advantage.
Which states are in WISeR? Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
How long does a WISeR decision take? CMS says participants typically issue a determination within 3 days, and within 2 days for expedited requests. Most response times will be within 72 hours.
Sources (accessed October 19, 2026)
- CMS, WISeR Model (page last modified 10/19/2026)
- CMS, WISeR Model Provider Factsheet
- CMS, WISeR Model Frequently Asked Questions (page last modified 09/22/2026)
- CMS, WISeR Provider and Supplier Operational Guide (cited for the location of the code appendices only; not read in full)
- CMS, WISeR Exemption Program Provider Factsheet (linked only; not read)