Background
General information
Coverage policies
Documentation requirements
Prior authorization request (PAR) submission requirements
Expedited requests
Claim submission requirements
Contact information
Educational events
Quick links and resources
The Wasteful and Inappropriate Service Reduction (WISeR) model will harness enhanced technologies such as artificial intelligence (AI) and machine learning (ML) to streamline the review process for certain items and services that are vulnerable to fraud, waste and abuse, helping people with Medicare receive safe and appropriate care and protecting federal taxpayers.
The WISeR model is the first innovation center model in which technology innovators will be the only model participants, and it is also the first model that incentivizes the use of cutting-edge tools to ensure payment complies with Medicare documentation, coverage, payment and coding rules.
Key points of the model:
Helps reduce clinically unsupported care by working with companies experience in using enhanced technologies to expedite and improve the review process for a preselected set of services that are vulnerable to fraud, waste and abuse.
Ensures people with Medicare receive the most appropriate care that supports the best health outcomes while decreasing costs and easing administrative burden on providers and suppliers who go through the prior authorization process.
Empowers patients to partner with their health care providers on the most clinically appropriate care plan; protects the taxpayer by decreasing fraud, waste and abuse; and focuses providers on care that has the most impact on the well-being of people with Medicare.
Question |
Answer |
Who? |
Beneficiary - The WISeR model only includes Medicare beneficiaries who are eligible for Medicare Part A and enrolled in Medicare Part B at the time of the prior authorization request or on the date of service for the claim subject to pre-payment review and: Aged 18 years or older Not enrolled in Medicare Advantage Not covered under the United Mine Worker Health and Retirement Funds Not eligible for Indian Health Services (IHS) Note: Beneficiaries who do not meet these criteria are exempt from prior authorization and medical review under the WISeR model. Providers - The WISeR model applies to providers billing Part B claims with a place of service (POS) office (11), home (12), ambulatory surgical center (24), and Part A outpatient claims with type of bill (TOB) 13X. Participants - Model participants are a new component to previously implemented prior authorization programs. Model participants will serve as the review contractor for the WISeR model. Participants in the WISeR model will be technology companies with expertise managing the prior authorization process for other payers using enhanced technology like AI. Model participants will be responsible for processing prior authorization requests and issuing affirmation or non-affirmation decisions. Model participants will also be responsible for performing the pre-payment clinical review for claims for model services submitted without prior authorization. There are 3 model participants in the WISER model for Novitas: New Jersey, Novitas jurisdiction (JL) the participant is Genzeon. Oklahoma, Novitas jurisdiction (JH), the participant is Humata Health. Texas, Novitas jurisdiction (JH), the participant is Cohere Health. |
What? |
The prior authorization process under this model will be implemented for the following items and services; however, additional services may be added on a quarterly basis: Electrical nerve stimulators Sacral nerve stimulation for urinary incontinence Phrenic nerve stimulator Vagus nerve stimulation Induced lesions of nerve tracts Epidural steroid Injections for pain management excluding facet joint injections Percutaneous vertebral augmentation (PVA) for vertebral compression fracture Cervical fusion Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee Hypoglossal nerve stimulation for obstructive sleep apnea Incontinence control devices Diagnosis and treatment of impotence Percutaneous image-guided lumbar decompression for spinal stenosis Skin and tissue substitutes Items and services included in the WISeR model can be found in Appendix A of the Wasteful and Inappropriate Service Reduction (WISeR) Model Provider and Supplier Operational Guide. The WISeR model does not change Medicare coverage or payment policy. Healthcare coverage for people with Medicare will not change, and they retain the freedom to seek care from their original Medicare provider or supplier of choice. Reimbursement to providers and suppliers for covered items and services will not change under the model. The WISeR model does not apply to patients with Medicare Advantage and will have no impact on them. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed. However, a provider or supplier may request an expedited review, if needed. |
When? |
Providers can begin submitting WISeR model prior authorization requests on January 5, 2026, for dates of service on or after January 15, 2026. |
Where? |
The WISeR model applies to services rendered in the following states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington |
Why? |
The WISeR model focuses on a specific subset of items and services that may have little to no clinical benefit for certain patients and that historically have had a higher risk of waste, fraud and abuse. |
How? |
Providers or suppliers in a designated state for the model who submit a prior authorization request for covered services will send all relevant information to support Medicare coverage of the selected services either directly to the WISeR model participant for that state or to Novitas, which will then route it to the model participant. The model participant will use enhanced technology to support coverage determinations and seek medical review by clinicians with relevant expertise, as needed. Model participants will notify the provider or supplier of the decision. Click the link below to learn more about each model participant and how to interact with them: |
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services. For more information on coverage and documentation requirements, refer to:
Section 6.2 Required documentation
For any service or item to be covered by Medicare, it must:
Be eligible for a defined Medicare benefit category.
Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Meet all other applicable Medicare statutory and regulatory requirements.
Providers submit a PAR via the WISeR model participant or to Novitas (do not submit requests to both):
Model participant for New Jersey is Genzeon, for PAR submission instructions refer to:
Model participant for Oklahoma is Humata Health, for PAR submission instructions refer to:
Model participant for Texas is Cohere Health, for PAR submission instructions refer to:
Novitas Solutions
The requester can submit an expedited review of the PAR if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. If the model participant confirms the risk, the model participant will process the PAR and communicate a decision to the requester within 2 days of receipt of the expedited request.
To avoid mailing delays with expedited requests, providers are encouraged to use electronic submission options and submit directly to the model participant.
If medical documentation does not support an expedited process, the request will be subject to the normal timeframe.
WISeR model prior authorization claims submission guidelines can be found in the article WISeR (Wasteful and inappropriate service reduction) model prior authorization (PA) claims submission guidelines.
Website:www.genzeon.com
Portal: https://portal.hip.one
Mailing address (coversheet coming soon)
Genzeon Corp.
256 Eagleview Blvd., Suite 509
Exton, PA 19341
Clinical questions: wiser@humatahealth.com
Humata WISeR portal: http://psi.humatahealth.com
Phone: (855) 430-6299
Email: wiser.support@coherehealth.com
For general questions regarding the WISeR model, please contact the Novitas Prior Authorization Contact Center.
Phone: (855)340-5975 available Monday - Friday (excluding holidays), 8 a.m. - 6 p.m. ET
Fax number: 833-200-9268
Mailing address:
Novitas Solutions
JL/JH Prior Authorization Requests (specify jurisdiction)
PO. Box 3702
Mechanicsburg, PA 17055
Priority mailing address:
Novitas Solutions
Attention: JL/JH Prior Authorization Requests (specify jurisdiction)
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
Please visit our educational event calendar (JH) (JL) for all available training opportunities and to register to participate in the webinars. Novitas has conducted and will continue to conduct WISeR webinars, if unable to attend, please view the recordings below or register for upcoming events.
Date |
Time |
Event Title |
Registration options |
Webinar Links* |
Friday, December 12, 2025 |
Start: 10:00 a.m. (ET) 9:00 a.m. (CT) End: 11:30 a.m. (ET) 10:30 a.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model - Oklahoma Providers Effective for dates of service on and after January 15, 2026, CMS is implementing the 6-year prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for services provided in jurisdictions JH and JL for New Jersey, Oklahoma, and Texas states only. The WISeR Model, created by CMS, is partnering with organizations (referred to as participants) experienced in applying Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and reasonable and necessary Medicare coverage for select items and services. CMS partnered with participant Humata Health to conduct prior authorization and prepayment reviews for services provided in Oklahoma to eligible Part A and B Medicare beneficiaries. Join this webinar to prepare for the WISeR prior authorization process and learn more about Humata Health. Audience: This presentation is intended for Part A and B Medicare providers rendering services in Oklahoma only. |
This event is intended for Oklahoma providers |
View recording Take survey |
Thursday, December 18, 2025 |
Start: 10:00 a.m. (ET) 9:00 a.m. (CT) End: 11:30 a.m. (ET) 10:30 a.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model - Texas Providers Effective for dates of service on and after January 15, 2026, CMS is implementing the 6-year prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for services provided in jurisdictions JH and JL for New Jersey, Oklahoma, and Texas states only. The WISeR Model, created by CMS, is partnering with organizations (referred to as participants) experienced in applying Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and reasonable and necessary Medicare coverage for select items and services. CMS partnered with participant Humata Health to conduct prior authorization and prepayment reviews for services provided in Oklahoma to eligible Part A and B Medicare beneficiaries. Join this webinar to prepare for the WISeR prior authorization process and learn more about Humata Health. Audience: This presentation is intended for Part A and B Medicare providers rendering services in Texas only. |
This event is intended for Texas providers |
View recording Take survey |
Thursday, December 18, 2025 |
Start: 1:00 p.m. (ET) 12:00 p.m. (CT) End: 2:30 p.m. (ET) 1:30 p.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model - New Jersey Providers Effective for dates of service on and after January 15, 2026, CMS is implementing the 6-year prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for services provided in jurisdictions JH and JL for New Jersey, Oklahoma, and Texas states only. The WISeR Model, created by CMS, is partnering with organizations (referred to as participants) experienced in applying Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and reasonable and necessary Medicare coverage for select items and services. CMS partnered with participant Humata Health to conduct prior authorization and prepayment reviews for services provided in Oklahoma to eligible Part A and B Medicare beneficiaries. Join this webinar to prepare for the WISeR prior authorization process and learn more about Humata Health. Audience: This presentation is intended for Part A and B Medicare providers rendering services in New Jersey only. |
This event is intended for New Jersey providers |
View recording Take survey |
Wednesday, January 7, 2026 |
Start: 10:00 a.m. (ET) 9:00 a.m. (CT) End: 11:30 a.m. (ET)10:30 a.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model - Oklahoma Providers Effective for dates of service on and after January 15, 2026, CMS is implementing the 6-year prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for services provided in jurisdictions JH and JL which includes New Jersey, Oklahoma, and Texas. The WISeR Model, created by CMS, is partnering with organizations (referred to as participants) experienced in applying Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and reasonable and necessary Medicare coverage for select items and services. CMS partnered with participant Humata Health to conduct prior authorization and prepayment reviews for services provided in Oklahoma to eligible Part A and B Medicare beneficiaries. Join this webinar to prepare for the WISeR prior authorization process and learn more about Humata Health. |
This event is intended for Oklahoma providers |
View recording Take survey |
Wednesday, January 7, 2026 |
Start: 2:00 p.m. (ET)1:00 p.m. (CT) End: 3:30 p.m. (ET) 2:30 p.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model - Texas Providers Effective for dates of service on and after January 15, 2026, CMS is implementing the 6-year prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for services provided in jurisdictions JH and JL which includes New Jersey, Oklahoma, and Texas. The WISeR Model, created by CMS, is partnering with organizations (referred to as participants) experienced in applying Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and reasonable and necessary Medicare coverage for select items and services. CMS partnered with participant Cohere to conduct prior authorization and prepayment reviews for services provided in Texas to eligible Part A and B Medicare beneficiaries. Join this webinar to prepare for the WISeR prior authorization process and learn more about Cohere. |
This event is intended for Texas providers |
View recording Take survey |
Thursday, January 8, 2026 |
Start: 10:00 a.m. (ET) 9:00 a.m. (CT) End: 11:30 a.m. (ET) 10:30 a.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model - New Jersey Providers Effective for dates of service on and after January 15, 2026, CMS is implementing the 6-year prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for services provided in jurisdictions JH and JL which includes New Jersey, Oklahoma, and Texas. The WISeR Model, created by CMS, is partnering with organizations (referred to as participants) experienced in applying Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and reasonable and necessary Medicare coverage for select items and services. CMS partnered with participant Genzeon to conduct prior authorization and prepayment reviews for services provided in New Jersey to eligible Part A and B Medicare beneficiaries. Join this webinar to prepare for the WISeR prior authorization process and learn more about Genzeon. |
This event is intended for New Jersey providers |
View recording Take survey |
Tuesday, February 3, 2026 |
Start: 1:00 p.m. (ET) 12:00 p.m. (CT) End: 2:30 p.m. (ET) 1:30 p.m. (CT) |
Wasteful and Inappropriate Service Reduction (WISeR) Model Prior Authorization Process CMS implemented the prior authorization Wasteful and Inappropriate Service Reduction (WISeR) Model for dates of service on and after January 15, 2026, for services provided in New Jersey, Oklahoma, and Texas and billed to Novitas. The WISeR Model includes companies (referred to as participants) who will leverage expertise managing the prior authorization process using enhanced technology to ensure timely, reasonable and necessary Medicare coverage decisions for select items and services. This webinar will provide an overview of the WISeR Model and prior authorization guidelines and identify valuable resources to navigate the WISeR Model process. Join this webinar to gain a better understanding of the WISeR Model and review answers to commonly asked questions regarding prior authorizations. |
This event is intended for Oklahoma, Texas and New Jersey providers |
View recording Take survey |
Genzeon: https://www.genzeon.com/wiser-nj-prior-auth-medicare/
Humata Health: https://www.humatahealth.com/ok-providers
Cohere Health: https://coherehealth.zendesk.com/hc/en-us/categories/37195844645399-Medicare-Novitas-Learning-Center
For more information about the WISeR model and the prior authorization process, refer to the below references.
Prior Authorization Code Lookup Tool (
JH) (
JL)
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