Participating in CMS WISeR in Ohio with CGS Administrators
Overview
Prior Authorization
Pre-Payment Medical Review
Important Dates
Forms & Documents
Educational Opportunities
Resources & Links
Contact & Support
Overview
The Centers for Medicare & Medicaid Services’ (CMS) Wasteful and Inappropriate Services Reduction (WISeR) Model tests the use of enhanced technology to decrease certain wasteful (low-value) services shown to have little to no clinical, evidence-based benefit. Technology companies participating in the model will help streamline the review of medical necessity for select items and services earlier in the claims process to: 1) reduce inappropriate utilization, 2) lower spending in Original Medicare, 3) expedite decision making and (4) ease provider administrative burden.
Innovaccer applied to participate in WISeR, and CMS selected Innovaccer for participation in the Model for the MAC Jurisdiction of J15 CGS and the state of Ohio. The designated state is the WISeR Model Participant’s WISeR Jurisdiction.
Goals
The WISeR Model aims to:
Focus health care spending on items and services that will improve patient well-being
Apply commercial payer processes that may be faster, easier and more accurate
Increase transparency on existing Medicare coverage policy
De-incentivize and reduce use of medically unnecessary care
Model Timeframe
2026
2027
2028
Performance Period One
January - December
2029
2030
2031
Performance Period One
January - December
Performance Period One
January - December
Performance Period Two
January - December
Design
WISeR does not change Medicare coverage or payment policy.
Providers have a choice: they can submit a prior authorization request before providing a serviceor opt out and have their claim subject to pre-payment medical review for the items and services CMS has included in WISeR.
Innovaccer will apply our technology in Ohio to assess coverage determinations for a select set of items and services that:
May pose concerns related to patient safety if delivered inappropriately
Have existing publicly available coverage criteria
May involve prior reports of fraud, waste and abuse
Examples of selected items and services include:
skin and tissue substitutes
implantation of electrical nerve stimulators
knee arthroscopy for knee osteoarthritis
The model excludes inpatient-only services, emergency services, services that would pose a substantial risk to patients if delayed, and services provided to people with Medicare Advantage.
All recommendations for non-payment or non-affirmation will be determined by appropriately licensed clinicians who will apply standardized, transparent and evidence-based procedures to their review.
Health care coverage for Medicare beneficiaries will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice.
Prior Authorization
Beginning on January 5, 2026, for dates of service on or after January 15, 2026, providers and suppliers will submit ALL Prior Authorization Requests (PAR) through CGS or the Electronic Submission of Medical Documentation (esMD) utilizing the approved WISeR Prior Authorization Request Form.
IMPORTANT: All prior authorization requests for WISeR must be submitted with the PAR 457 form.
CGS will forward your information to Innovaccer. Innovaccer will review the request and send CGS, the provider/supplier, and the beneficiary a decision letter with an associated Unique Tracking Number (UTN). Prior authorization decisions and associated UTNs are valid for 120 calendar days from the decision date.
Decision Letters will be sent to the provider/supplier via the same method used to submit the PAR.
If the PAR was submitted through the myCGS Portal, CGS will post the decision letter to the myCGS Portal. A copy will be mailed to the beneficiary.
If the PAR was submitted via Fax to CGS, Innovaccer will return the decision letter to the same fax number it received from the provider. A copy will be mailed to the beneficiary.
If the PAR was submitted via Mail to CGS, Innovaccer will mail the decision letter via USPS to the address on file for the provider/supplier. A copy will be mailed to the beneficiary.
If the PAR was submitted via the esMD to Innovaccer, Innovaccer will return the decision letter via the esMD. A copy will be mailed to the beneficiary.
Once available, If the PAR was submitted via the Innovaccer WISeR Portal, Innovaccer will return the decision letter via the Innovaccer WISeR Portal. A copy will be mailed to the beneficiary.
Pre-Payment Medical Review
For model service claims submitted without prior authorization:
CGS will suspend the claim and forward it to the model participant.
Innovaccer will send the billing provider/supplier an Additional Documentation Request (ADR) letter.
Provider/Supplier should send documentation to Innovaccer within 45 days from the date of ADR letter.
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Educational Opportunities
Upcoming Webinars
Description
12/12/2025
Innovaccer Webinar to Ohio Hospital Association Members *Since this is being hosted by the Ohio Hospital Association (OHA), please note that this webinar is only open to OHA Members.
Innovaccer Webinar to Ohio Hospital Association Members *Since this is being hosted by the Ohio Hospital Association (OHA), please note that this webinar is only open to OHA Members.
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