Payer Policy | WISeR Prior Authorization Model: New Exemption Program and What Providers in 6 States Should Do - Effective Date: January 01, 2026 through December 31, 2031

Rcmaxis Billing & Policy Update  ·  Posted September 28, 2026  ·  Effective: January 01, 2026 through December 31, 2031

Summary of the Rule or Edit Change

The WISeR (Wasteful and Inappropriate Service Reduction) Model adds prior authorization to Original Medicare for selected services in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. It started January 1, 2026 and runs through December 31, 2031. Requests have been accepted since January 5 for services on or after January 15. Each state has a technology-enabled review company: Cohere Health (Texas), Genzeon (New Jersey), Humata Health (Oklahoma), Innovaccer (Ohio), Virtix Health (Washington) and Zyter (Arizona). The model doesn't apply to Medicare Advantage, and it excludes inpatient-only services, emergency services and services that would put patients at risk if delayed.

The current operational guide (version 7.0, updated July 24, 2026) lists 13 service categories. They include skin substitutes for chronic lower extremity wounds, epidural steroid injections, cervical fusion, electrical nerve stimulators, sacral and hypoglossal nerve stimulation, vagus and phrenic nerve stimulation, incontinence control devices, percutaneous vertebral augmentation, induced lesions of nerve tracts, treatment of impotence, and knee arthroscopy for osteoarthritis. Decisions come within 3 calendar days (2 for expedited requests). A non-affirmed request can be resubmitted as many times as needed, with a peer-to-peer review available. Skip prior authorization and the claim goes to pre-payment medical review instead.

The newest piece is the exemption program, which began in July 2026. An individual provider earns exemption by submitting at least 10 prior authorization requests in an assessment period and meeting a minimum approval rate. Exemption is granted per NPI (not per practice), covers all WISeR services across Part A and Part B and all sites of care, starts at the beginning of a quarter and lasts at least a year. Review companies re-check with up to 10 additional documentation requests a year and give at least 60 days' notice before removing an exemption. Claims for exempt providers need the NPI in the right field: rendering provider in the office or home, referring or ordering provider in an ASC, and operating provider in a hospital outpatient department.

The model is also under scrutiny. On September 15, 2026, STAT reported that documents released through a Freedom of Information Act lawsuit show a rushed rollout, including a warning from one vendor that a working product by the launch date wasn't realistic.

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