Providers and suppliers can submit a prior authorization request directly to Innovaccer or through CGS. CGS will forward the request to Innovaccer within one (1) calendar day, or as soon as practicable. Providers and suppliers can submit a prior authorization to Innovaccer through our electronic portal (https://wiser.innovaccer.us) or by fax (419-965-6730).

Questions about a specific prior authorization request should be directed to Innovaccer. Provider contact center agents are available every Monday through Friday from 8 AM eastern time through 5 on eastern time by calling 202-796-1619. Providers can also email Innovaccer at ohcmswiser-inquiry@innovaccer.com to inquire about the status of specific cases.  
The CMS WISeR Model Help Desk (WISeR@cms.hhs.gov) can also provide support with program-specific, operational, or implementation questions related to the WISeR model. The CMS WISeR Model Help Desk is unable to verify or provide information about specific prior authorization requests that are submitted to a WISeR Model Participant or MAC and will refer such inquiries to the participant.

WISeR participants must issue determinations within three (3) calendar days of receiving a complete standard prior authorization request. (Note: the three (3) day turnaround time applies to the WISeR participant. For prior authorization requests sent to a MAC rather than to a WISeR participant, additional time may be needed for the MAC to process and forward the information to the participant, and then to forward the decision back to the provider or supplier. As such, submitting prior authorization requests directly to a WISeR participant is the most expeditious approach. Also, CMS measures turnaround time as the number of days between the day that the WISeR participant receives the prior authorization request and the day that the WISeR participant communicates a determination, even if the determination does not include a UTN.)

The WISeR Model applies to services furnished in Hospital Outpatient Departments (HOPDs), Ambulatory Surgery Centers (ASCs), office and home settings in selected states. For services delivered in HOPDs or ASCs, prior authorization and pre-payment review will be implemented for the facility-based encounter or claim, though professional claims can later be flagged through the associated code list in the case of any non-affirmed or denied facility claims. Meanwhile, professional encounters and claims will be subject to prior authorization and pre-payment review for services delivered in the office or home in selected states.

If the facility is an eligible site of service in an eligible state and renders an eligible item or service to an eligible beneficiary, that service would require prior authorization review or pre-payment medical review under the WISeR Model. The site of service in a non-WISeR state would not submit WISeR items and services for prior authorization. For example, if a provider has Hospital Outpatient Departments (TOB 13X, corresponding to POS 19 and 22 on professional claims) in Oklahoma (a WISeR state) and Kansas (not a WISeR state), and the provider traditionally bills through JH Novitas (a WISeR Medicare Administrative Contractor [MAC]), only WISeR-eligible items and services at the Oklahoma location require prior authorization or pre-payment medical review.

No, items or services are included in WISeR only if they are furnished in an eligible state and billed through a WISeR participating MAC for that jurisdiction. Items or services rendered by providers or suppliers that bill through a nonparticipating MAC are not subject to WISeR prior authorization or pre-payment medical review, even if the provider or supplier is located in a WISeR state.

The "primary codes" in Appendix A of the WISeR Provider and Supplier Operational Guide (PDF) are subject to prior authorization and pre-payment review in WISeR selected states. Appendix B contains ICD-10 codes for a subset of WISeR services; they narrow the CPT codes for the services selected in WISeR to align with the relevant NCD or LCD. For those services, CPT codes billed without an ICD-10 code in Appendix B are out of scope and will not be included in WISeR.
Associated codes listed in Appendix C are related to a WISeR item or service. These codes are not designed to be treated as standalone services and will not require separate prior authorization or pre-payment review on their own. Claims for associated codes will be paid (assuming all existing requirements relevant to the associated codes are met) if a primary code for a WISeR select item or service in Appendix A is affirmed during prior authorization or approved during pre-payment review. Claims for associated codes will be denied, and/or payments for associated codes will be recouped when furnished as part of a WISeR episode in which a primary code for a WISeR select item or service has a non-affirmed prior authorization or is denied during pre-payment review.

The available submission methods for prior authorization requests are the 1) Innovaccer Provider Portal; 2) myCGS Portal; 3) esMD; or 4) Fax

A provisional affirmation is valid for 120 calendar days from the date of the decision. If the service is not rendered within that window, a new prior authorization request must be submitted. For services requiring repeat instances (such as skin substitutes), the same UTN may be used for each claim for up to 120 days from the determination date.

Yes, a new authorization is required if the Place of Service or Facility changes.

Yes, a new authorization is required if the rendering provider or physician changes.

If you plan to render and bill for multiple WISeR services, report all applicable WISeR Appendix A codes on the same PAR to receive one UTN for all services.
Using skin substitutes (CPT codes 15271 & 15272) as an example: If a claim is submitted with the same beneficiary, DOS, and includes only ONE CPT code (e.g. 15271 primary code), the second CPT code (e.g. 15272 secondary code) will suspend for prepayment medical review. However, the claim denies since Innovaccer cannot issue a decision for CPT code 15272 (secondary code) without CPT code 15271 (primary code).

No, the WISeR Model applies to hospital outpatient department services reported on type of bill (TOB) 13X claims.

The Innovaccer WISeR Provider Portal is available for providers to submit, track, and manage WISeR prior authorization cases electronically. The URL for the Provider Portal is https://wiser.innovaccer.us/.

No. The Innovaccer Portal and the myCGS Portal are separate systems. You will only be able to check the status of cases created directly in the Innovaccer Portal and vice versa. The myCGS Portal is still available for case creation and viewing, but these cases will not appear in the Innovaccer Portal. Checking case status will require you to contact CGS directly.

The UTN displays under the WISER ID once this is generated from the Medicare shared system.

The claim will be suspended for prepayment review if a UTN is not included.

No. Do not submit a claim for payment until the UTN has been received. Claims submitted without a UTN will be forwarded to Innovaccer for pre-payment medical review, which may delay payment. Hold the claim until the UTN is provided.

First, verify that the National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) information on your case submission are correct and properly linked in the Medicare Shared Systems. If the information does not match, the case will need to be dismissed and resubmitted with corrected information. If you have confirmed the information is correct and still have not received a UTN after allowing sufficient processing time, contact ohcmswiser-inquiry@innovaccer.com for assistance.

Claims received without a UTN will be forwarded to Innovaccer for pre-payment medical review. Innovaccer will mail an Additional Documentation Request (ADR) letter to the provider. Supporting documentation must be submitted within 45 days of the ADR letter date. If no documentation is received within 45 days, Innovaccer will notify CGS to deny the claim due to lack of supporting documentation.

A dismissal occurs when a prior authorization request cannot be processed due to incomplete or invalid information, when the request falls outside the scope of WISeR, or when a duplicate request is submitted. Unlike a non-affirmation — which is a clinical determination that the service does not meet Medicare coverage criteria — a dismissed request is never reviewed for medical necessity.

A duplicate is a new prior authorization request submitted by the same provider or supplier for the identical beneficiary and WISeR select item or service before a determination has been issued on any earlier request for that same case. Duplicate requests are subject to dismissal.

Review the reason listed in the dismissal letter, correct the error, and resubmit using the same submission procedures. When resubmitting, you must include all original documentation. If the dismissed request was an initial request, the subsequent corrected request should also be marked as an initial request — not a resubmission.

No, if an authorization is dismissed, a new Initial submission is required. Innovaccer cannot reverse a dismissal letter. If you received a dismissal and believe it was an error please submit a new request.

Yes, this dismissal letter is correct. Innovaccer may have sent an Affirmed decision to CGS to generate the UTN, but the determination was later rejected as an error when the UTN was requested.

Unlimited resubmissions are permitted under the WISeR Model.

For a prior authorization request to be considered a Resubmission, the following information must match the INITIAL request: provider facility, rendering provider, member information, DOS and CPT codes. If any of the criteria are different, the request is considered an INITIAL submission, not a RESUBMISSION.

The most recent non-affirmed UTN must be used for resubmission as well as an exact match of the beneficiary's first name, last name, and date of birth.

Peer-to-peer scheduling is completed through the Innovaccer Provider Portal. Once you are in the Portal, enter this as a Resubmission with the UTN of the most recent non-affirm decision.
Once you enter the UTN, the portal will ask you if you would like to schedule a peer to peer discussion. After you have entered and submitted all the required information, someone from our clinical center will contact you to schedule your requested peer to peer.  

 For model service claims submitted without prior authorization, CGS will suspend the claim and forward it to Innovaccer. 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.
There are three ways to submit ADR documentation:

1. Innovaccer Portal: https://wiser.innovaccer.us
2. myCGS Portal:
a. Part A: https://cgsmedicare.com/parta/pa/wiser.html
b. Part B: https://cgsmedicare.com/partb/pa/wiser.html
c. Fax: 419-965-6730

Innovaccer will link documentation with the pending claim and perform a medical necessity review. Innovaccer will communicate the medical necessity review determination to CGS and CGS will process the claim based on Innovaccer’s prepayment medical review decision.

No, decision letters are not sent for prepayment reviews. Innovaccer sends the decision to CGS for processing.

Providers and suppliers that demonstrate a strong track record of compliance with Medicare coverage, coding, and payment requirements may qualify for Gold Carding as part of WISeR. With Exemption Status, providers are not required to submit prior authorization requests for WISeR Select Items and Services for a specified period.

To qualify for Gold Card Status, providers must meet the following requirements:
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Providers will be added to the Exemption Status list on a rolling quarterly basis, and each notification will include the specific effective date for that provider's status.

Gold Cards remain in effect for a defined term. Innovaccer will periodically review all exempted providers. If a provider no longer meets the eligibility criteria, their Gold Card Status may be revoked, at which point standard prior authorization requirements will resume.

The WISeR Program exempts individual NPIs only – group NPIs are not exempt. Keep this in mind when registering and submitting cases.