CMS Documentation Requests Frequently Asked Questions (FAQs)

Frequently Asked Questions (FAQs)

A.     What is the WISeR Model and why is it being implemented?

The WISeR Model (Wasteful and Inappropriate Services Reduction Model) is a new five-year payment and service-review model created by the Center for Medicare & Medicaid Innovation (CMMI) to bring advanced, technology-supported medical review into Medicare Fee-for-Service (FFS). It is designed to use AI-enabled tools, data analytics, and clinical expertise—supplied by contracted WISeR Participants to improve the accuracy and efficiency of prior authorization and pre-payment medical review for selected items and services.

The model operates in partnership with Medicare Administrative Contractors (MACs) and applies only in selected states. It does not change existing Medicare coverage, payment, or appeals rules. Instead, it changes how certain high-risk services are reviewed before payment is made.

B.     Which services require prior authorization in New Jersey?

Services requiring prior authorization are the WISeR “Select Items and Services.”
These are specific HCPCS/CPT-coded services that CMS has flagged as:

·         high risk for fraud, waste, or abuse

·         clinically unsupported at high rates

·         historically prone to improper payment

New Jersey providers will be required to request prior authorization only for these Select Items and Services.

C.    When does the program begin and end?

The WISeR Model runs for six years, across two consecutive three-year agreement periods.

·         Program Start: January 1, 2026

·         Program End: December 31, 2031

D.    Who is the MAC for New Jersey?

New Jersey is served by Novitas Solutions, Inc., operating as the JL MAC under the WISeR Model.

E.      Are there penalties for non-compliance?

Yes. While WISeR does not impose monetary fines, non-compliance results in claim payment consequences:

·         Claims will be automatically suspended if prior authorization is not submitted for Select Items and Services.

·         Claims will undergo pre-payment medical review by the WISeR Participant.

·         Claims may be denied if documentation does not support Medicare requirements.