WISeR Prior Authorization Process and Exemption Status Program

Who needs to participate in WISeR?

Physicians in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington within specific Medicare Administrative Contractor (“MAC”) jurisdictions (JL, J15, JH, and JF) that provide the identified services. CMS intends to expand the model to more states.

However, it is mandatory for Medicare-enrolled physicians and practices to submit prior authorization requests for selected procedures to a WISeR participant (a technology company or MAC). The WISeR participant companies are:

Where can I find the selected services that require prior authorization?

Access the selected services as well as the pain medicine and associated anesthesia codes here. More details are available at CMS’ Provider and Supplier Information webpage. 

How do I begin the prior authorization process?

Physicians and practices have two options under WISeR to receive coverage determinations: 

1. Submit a prior authorization request to receive a determination prior to administering WISeR select items and services, as described in Sections 3 and 4, or 

2. Furnish WISeR select items and services immediately and wait for the determination through pre-payment review, as described in Section 7.2.

Comprehensive details including data elements to include in authorization requests, process flow, timeline, and where to send requests are found in the WISeR Model Provider and Supplier Operational Guide 3.0

What is the timeline for receiving a determination of coverage?

For non-urgent cases, WISeR vendors or the MAC will typically issue a determination to the requester within 3 days of receiving the initial or resubmitted request. If delays could seriously jeopardize a patient’s life, health, or ability to regain maximum function, an expedited request can be issued a decision to the requester within 2 days of receipt of the request.

What is the WISeR Model Exemption Status or “gold carding” program?

The WISeR Model includes an exemption status, or “gold carding,” program that allows eligible physicians and health care organizations with a demonstrated history of compliance with Medicare requirements to earn an exemption from WISeR prior authorization and pre-payment review. Exemption status is granted at the NPI level.

Physicians must have submitted at least 10 prior authorization requests across WISeR Select Items or Services and meet the applicable WISeR vendor’s affirmation threshold. Specific criteria may vary by WISeR vendor.

For complete eligibility criteria and FAQs, see the CMS WISeR Model Exemption Status Program Fact Sheet (PDF)

WISeR Vendor Resources

Exemption status criteria and implementation may vary by WISeR vendor. Physicians should review information from the WISeR vendor serving their state:

• Texas: Cohere Health, Novitas Solutions
• New Jersey: Genzeon Corporation
• Oklahoma: Humata Health
• Ohio: Innovaccer
• Washington: Virtix Health
• Arizona: Zyter

Other relevant and up-to-date resources to review include:

• CMS Manual for WISeR including changes to services and start date (PDF)

• WISeR Model Frequently Asked Questions  
  (Updated 12/23/2025)

• WISeR Provider and Supplier Operational Guide (PDF)  
  (Updated 12/23/2025) 

• WISeR Provider Factsheet (PDF) Includes services (page 2) and prior authorization process flow (page 3)

• All other details are available at Provider and Supplier Information