WISeR Model States and Services: Full List and A/R Impact

TL;DR: CMS sets the WISeR model states and services: Original Medicare claims in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, across 13 active service categories, through December 31, 2031. Skip prior authorization on one of those services and the claim stops at the MAC for pre-payment review. From there, your own documentation turnaround controls how long it ages.

A pain management group in Ohio bills an epidural steroid injection the way it always has. The payment never posts. If that sounds like your Medicare aging report, check the WISeR model states and services list first, because the claim likely sits in suspense with a 45-day documentation clock running against it. Our earlier post on what the WISeR model does to your Medicare A/R covers the choice between prior authorization and pre-payment review. The other half of the question is scope and mechanics: every state, every service category, the review clock CMS wrote into the rules, and the path a held claim takes back to cash. Any medical billing services team working in these states needs that map.

Which states does the WISeR model cover?

WISeR covers six states. Each one maps to a single technology company and a single MAC jurisdiction. That pairing decides which reviewer sees your records and which local coverage determinations it applies, so the state half of the WISeR model states and services question carries more weight than it looks.

The model applies to Original Medicare providers and suppliers in those six states. Medicare Advantage and Railroad Medicare beneficiaries sit outside it, along with providers already under UPIC review. According to the CMS WISeR model page, the model runs six performance years, from January 1, 2026 to December 31, 2031. Prior authorization requests opened January 5, 2026, for services furnished on or after January 15, 2026. That later date is when pre-payment review began for anyone who skipped the request.

Which services does WISeR review?

Thirteen service categories are active, and two more sit on the list with implementation delayed. An existing national or local coverage determination defines every one of them. CMS chose services where a written coverage policy already existed. That choice explains why WISeR review tests the chart against criteria your clinicians may never have documented to, even on procedures they have performed for years.

Source: the WISeR Provider and Supplier Operational Guide, CMS, version 7.0 (2026).

Two scope details decide whether a given claim lands in review. The code list runs narrower than the category names suggest. CMS publishes the primary codes in Appendix A of the operational guide, and Appendix C ties certain CPT codes to specific ICD-10 diagnoses. A CPT code billed without an Appendix C diagnosis falls outside the model for that service. Skin substitutes also vary by state. Noridian withdrew the governing LCD in JF, so the participants in Arizona and Washington are not reviewing them.

Exposure clusters by specialty. Spine and interventional pain carry the heaviest load, with nerve tract lesions, electrical nerve stimulators, vertebral augmentation, epidural steroid injections and cervical fusion all in scope. For those groups, the pain management billing guide and the WISeR model states and services table belong side by side. Knee arthroscopy pulls in orthopedics, covered in our orthopedic billing guide. Urology, sleep medicine and wound care each carry at least one category. Review applies in the physician office, the ambulatory surgery center, the hospital outpatient department and the home.

How WISeR pre-payment review affects accounts receivable

Pre-payment review moves the payment clock from the day you bill to the day your documentation arrives. When a practice furnishes a WISeR service without a prior authorization decision and bills it, the MAC suspends the claim and forwards it to that state's WISeR participant. The participant then requests the clinical documentation. Your practice has 45 calendar days from the date of that request to send the records. Once the participant has everything, it owes the MAC a medical necessity determination within 3 calendar days. The MAC finishes processing the claim from there.

CMS's share of that timeline runs in days. Yours can run for weeks. Every day a documentation request sits unanswered is a day the claim ages on your books. No aging report labels the reason. Practices that answer in the first week see a short hold. When requests land in a shared inbox, a team can burn most of the 45 days before anyone opens the envelope. On the aging report, that claim looks like slow Medicare payment rather than an unanswered request.

Why one review can hold several lines of revenue

The primary procedure is not the only thing waiting. CMS pays associated codes only when the participant affirms the related primary code or the MAC approves it on pre-payment review. If the primary code fails, the MAC denies the associated codes, or recoups them if they already paid. That rule turns one determination into a decision about several lines at once. A line your team posted as paid and closed can come back weeks later as a recoupment, landing as a negative balance on an account nobody is watching.

The denial and appeal path

A denial after pre-payment review counts as an initial payment determination. Every Medicare appeal right survives WISeR intact. The first level is a redetermination by the MAC. Your practice has 120 days from receiving the initial determination to file it. According to the CMS first-level appeals guidance, the MAC generally decides within 60 days of receiving the request. Stack those limits on top of the 45-day documentation window and a single claim can stay open for more than seven months before any second-level appeal. That is the real A/R exposure across the WISeR model states and services footprint: a denied claim that nobody sequences by deadline.

One more rule affects who carries the balance. For a service that received a non-affirmed prior authorization, CMS requires the provider to notify the beneficiary with an Advance Beneficiary Notice before furnishing it. Without a valid ABN on file, the practice generally keeps the liability rather than the patient.

Where WISeR A/R gets stuck

Across the WISeR model states and services, holds turn into write-offs at five predictable points.

• Documentation requests with no owner. The 45-day window runs whether or not anyone has claimed the request.
• Charts that show the procedure but not the criteria. A reviewer can only affirm what the record shows against the NCD or LCD. Missing conservative-care history or imaging turns into a denial.
• Associated codes treated as settled. A line posted as paid before the primary code clears can reverse into a recoupment.
• Denials worked in arrival order. The oldest denial sits closest to losing its 120-day redetermination window, and arrival order buries it.
• WISeR claims mixed into general Medicare aging. The pattern stays invisible until the older aging buckets swell.

None of the five starts at the payer. Every one is a workflow gap on the practice side of the claim, which is where the fix has to happen.

In-house, offshore or HRG: who catches a WISeR hold

The difference between a short hold and a write-off comes down to who sees the suspension and how fast they act on it. Practices billing in the WISeR model states and services footprint usually run one of three setups.

Practices that hold WISeR A/R steady treat it as its own category of claim, with its own owner and its own deadline tracking. Any of the three setups can do that. Whether yours does is the open question.

How HRG handles WISeR pre-payment review

Prior authorization stays with your practice. HRG works the billing side of WISeR: the claim, the documentation response, the denial, the appeal and the A/R that follows. Our U.S.-based billers work directly inside your EHR, clearinghouse and payer portals. A suspended claim or a documentation request shows up where your team already looks, not in a separate dashboard or a monthly PDF.

Weekly and monthly A/R reviews run by the billers themselves catch the WISeR-specific pattern early: a cluster of suspended claims on one service line, a run of associated codes waiting on a primary, a denial drifting toward its redetermination deadline. Our denial prevention work checks records against the governing NCD or LCD before they go to the reviewer. The cheapest appeal is the one you never have to file.

24 to 48 hours. That is HRG's denial response time. A WISeR denial goes back to the MAC as a redetermination long before the 120-day window gets tight.

Across more than 26 years, that model has produced a track record of 15 to 30 percent fewer denials and A/R days reduced by 15 to 25 days, along with a CFO-confirmed 98 percent first-pass claim acceptance rate. On coding, HRG provides coding consultation as needed. We do not perform coding. Your coders keep ownership of the CPT and ICD-10 selections that decide whether a claim falls inside the WISeR model states and services scope in Appendix C.

Get a read on your WISeR exposure

If your practice bills any of these services in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, your Medicare aging already shows how WISeR is treating you. Billing and RCM engagements with HRG run on a longer-term contract, scoped to what your practice needs. Want to see where your suspended and denied WISeR claims sit right now? Schedule a strategy call with Andy Garcia. No pitch. No pressure.

More on WISeR model states and services

Who decides whether Medicare pays a WISeR claim?

The WISeR participant sends a recommendation to the MAC. CMS requires that recommendations for non-payment come from appropriately licensed clinicians using standardized, evidence-based procedures. The MAC then issues the payment determination. HRG works the claim after that determination, including any redetermination request, which goes to the MAC rather than to the participant.

Can a practice earn an exemption from WISeR review?

Yes. CMS runs an exemption program, sometimes called gold carding, that grants status to an individual NPI after at least 10 prior authorization requests and an affirmation rate above a minimum threshold. Exempt status lasts at least one year. Because prior authorization requests stay with your practice, HRG does not build that record for you. What HRG does is keep the billing clean on claims from exempt and non-exempt providers alike.

Where does an exempt provider's NPI go on a WISeR claim?

The field depends on the setting. CMS directs the exempt NPI to the rendering provider field for office and home claims, the referring or ordering provider field for ambulatory surgery center claims, and the operating provider field for hospital outpatient claims. HRG billers place it according to the setting inside your own EHR, so an exemption you earned does not get lost on the claim form.

How fast does a WISeR prior authorization decision come back?

CMS sets a standard decision time of 3 calendar days. Expedited requests get a decision within 2 days, reserved for cases where delay could seriously jeopardize the patient's life or health. An affirmed decision stays valid for 120 calendar days, and its tracking number has to appear on the claim. Prior authorization stays with your practice, while HRG handles the billing and A/R once the claim goes out.

Will CMS add more services to WISeR?

CMS says it may update the service list during the performance period. It also plans to reevaluate the two delayed categories, deep brain stimulation and percutaneous image-guided lumbar decompression, in a future performance year. HRG tracks those updates against each client's service mix. A new category shows up in our A/R review before it shows up as a wave of suspended claims.

Six states now, a longer runway

WISeR runs through 2031. The WISeR model states and services list can grow before then. Practices that build a WISeR lane into their denial management process now will absorb any additions as routine work rather than as a new backlog.