CMS WISeR Model - Ohio

Participating in CMS WISeR in Ohio with CGS Administrators

Innovaccer WISeR Provider Portal

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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,
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:

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• 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: Performance Period One (January - December)
• 2027: Performance Period One (January - December)
• 2028: Performance Period One (January - December)
• 2029: Performance Period Two (January - December)
• 2030: Performance Period Two (January - December)
• 2031: 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 service or 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 the Innovaccer WISeR Portal, CGS or the Electronic Submission of Medical Documentation (esMD) utilizing the approved WISeR Prior Authorization Request Form (PAR-457).

IMPORTANT: All prior authorization requests for WISeR must be submitted with the PAR 457 form.

Submitting Directly to Innovaccer

Methods:

• Innovaccer WISeR Provider Portal
• Electronic Submission of Medical Documentation (esMD)
• Fax: 419-965-6730

Submitting through CGS

Methods:

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• myCGSPortal
• Fax: 615-660-5300
• Mail: CGS, PO Box 20203, Nashville, TN 37202

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.

Receiving Decision Letters

Decision Letters are sent to the provider or supplier via the same method used to submit the PAR.

• Submitted via the Innovaccer WISeR Provider Portal: Innovaccer will return the decision letter to the Facility Fax Number provided on the request form. A copy of the decision letter will also be mailed to the beneficiary.
• Submitted via myCGS Portal: CGS will post the decision letter to the myCGS Portal. A copy of the decision letter is faxed to the Facility Fax Number provided in the request if a Facility Fax Number is entered. A copy of the decision letter is also mailed to the beneficiary.
• Submitted via Fax: Innovaccer will return the decision letter to the Facility Fax number entered on the request form. A copy of the decision letter is also mailed to the beneficiary.
• Submitted via Mail to CGS: Innovaccer will mail the decision letter via USPS to the address on file for the provider/supplier. A copy of the decision letter is also mailed to the beneficiary.
• Submitted via esMD to Innovaccer: Innovaccer will return the decision letter via the esMD. A copy of the decision letter is faxed to the Facility Fax Number provided in the request if a Facility Fax Number is entered. A copy of the decision letter is also mailed to the beneficiary.

Pre-Payment Medical Review

Under the WISeR model, claims submitted for selected services without a valid prior authorization and Unique Tracking Number (UTN) are subject to a prepayment medical necessity review. This review ensures that services meet Medicare coverage, coding, and payment requirements before any payment is issued.

How the Prepayment Review Process Works

1. CGS suspends the claim and forwards it to Innovaccer for review.
2. Innovaccer mails an ADR letter with a unique barcode to your facility address on file.
3. You submit the required documentation - include the barcoded ADR letter on top of all records - within 45 calendar days of the ADR letter date.
4. CGS processes the claim based on Innovaccer's prepayment medical review determination.

Note: If you receive an ADR letter, it must be included on top of your documentation submission.

Submission deadline

45 calendar days from the date of your ADR letter. Late or incomplete submissions may result in claim delays or denial.

Ways to submit documentation:

• Fax: 419-965-6730
• Mail: Innovaccer, 201 Mission Street, Suite 2900, San Francisco, CA 94105

Examples of documentation may include:

• History and physical examination
• Evidence of failure of conservative therapy
• Plan of Care
• Physician and/or nursing progress notes
• Procedure records
• Radiology, pathology, and/or lab results
• Medication administration records
• Advance Beneficiary Notice (ABN), if applicable
• Any other documentation supporting medical necessity

Forms & Documents

• WiSeR Innovaccer Manual
• CMS WISeR Model Authorization Request Form (PAR 457)
• WISeR Provider and Supplier Operational Guide
• Innovaccer WISeR Provider Portal User Guide

Important Dates

Contact & Support

If you have a question or need assistance, please contact us by emailing us at ohcmswiser-inquiry@innovaccer.com or by phone at 202-796-1619.

Educational Opportunities

Upcoming Webinars

1. Date: 1/12/2026
   Description: Innovaccer Webinar to the Ohio State Medical Association (OSMA)
   Registration Link: Link to register

2. Date: TBD
   Description: General Model Overview and Enablement

3. Date: 12/12/2025
   Description: Previous Webinar- Innovaccer Webinar on WISeR Model to OHA Members
   Registration Link: Link to recording

4. Date: 12/17/2025
   Description: Previous Webinar- CGS & Innovaccer WISeR Model Webinar
   Registration Links: Instructions on how to view the recording Webinar Slides Link

Resources & Links

1. WISeR (Wasteful and Inappropriate Service Reduction) Model | CMS
2. WISeR Model Fact Sheet
3. WISeR Model Frequently Asked Questions
4. CGS WISeR Information Page
5. WISeR Provider and Supplier Operational Guide
6. Innovaccer WISeR Manual
7. Innovaccer WISeR Portal

Exemption Status

Providers and suppliers that demonstrate a strong track record of compliance with Medicare coverage, coding, and payment requirements may qualify for Exemption Status ("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.

Eligibility Criteria for Exemption Status

• Minimum request volume: The provider must have submitted at least 10 prior authorization requests for WISeR Select Items and Services during an exemption assessment period.
• Affirmation rate: A minimum of 90% of the submitted requests must be provisionally affirmed.
• Program standing: The provider must not appear on any applicable Medicare exclusion list.

Timeline

Innovaccer will begin issuing Exemption Status notifications in June 2026. 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.

Duration and Ongoing Review

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