Industry Watch Alert
WISeR Model Participants and Assigned Jurisdictions
| Participant | State(s) | MAC Jurisdiction | Summary |
|---|---|---|---|
| Cohere Health, Inc. | Texas | JH / Novitas | AI-driven prior authorization management platform. Will oversee utilization review for WISeR-covered items and services in Texas. |
| Genzeon Corporation | New Jersey | JH / Novitas | Provides healthcare automation and technology solutions. Will manage review processes and data integration for providers in New Jersey. |
| Humata Health, Inc. | Oklahoma | JH / Novitas | Specializes in payer technology and AI-assisted clinical review. Will manage medical review operations in Oklahoma. |
| Innovaccer Inc. | Ohio | J15 / CGS | Known for its healthcare data platform and analytics solutions. Will oversee prior authorization and pre-payment medical reviews in Ohio. |
| Virtix Health LLC | Washington | JF / Noridian | Clinical review and compliance firm providing independent medical necessity determinations. Assigned to Washington. |
| Zyter Inc. | Arizona | JF / Noridian | Digital health technology company experienced in care coordination and telehealth. Will manage the review process in Arizona. |
Vendor Role in the WISER MOdel
According to CMS, WISeR participants will:
Conduct prior authorization and pre-payment medical reviews for select outpatient and device-related services.
Employ clinicians with specialty expertise to verify compliance with Medicare coverage criteria.
Collaborate with CMS Medicare Administrative Contractors to receive and process provider submissions through fax, mail, or electronic systems.
Receive a performance-based share of savings tied to reductions in inappropriate or wasteful care.
Be evaluated on provider experience metrics, including timeliness and satisfaction with the prior authorization process
Wiser Model Purpose & Process
- The WISeR Model was created by the Center for Medicare & Medicaid Innovation to test new technology-enhanced payment and service delivery approaches in Original Medicare that reduce unnecessary treatments and prevent fraud, waste, and abuse, while maintaining or improving quality of care. Its primary aim is to ensure select items and services for Medicare beneficiaries meet established coverage criteria by leveraging advanced technologies and dedicated review organizations, thereby promoting safe, effective, and clinically necessary care without changing existing Medicare coverage or payment policies. [provider & supplier operational guide]
- Providers may submit prior authorization requests before servicing; non-submission triggers pre-payment review—a process requiring medical necessity documentation, NCD/LCD compliance, and clinical validation by WISeR participants.
- All determinations and reviews will be supervised by licensed clinicians with subject-matter expertise.
- Gold Card exemption is planned for select providers meeting documentation and compliance criteria, with further implementation details to be released by CMS.
Sources
- Centers for Medicare & Medicaid Services. Wasteful and Inappropriate Service Reduction (WISeR) Model – Frequently Asked Questions. Retrieved September 2025, from https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions CMS
- Centers for Medicare & Medicaid Services. Wasteful and Inappropriate Service Reduction (WISeR) Model – Fact Sheet. April 2025. Retrieved from https://www.cms.gov/files/document/wiser-fact-sheet.pdf CMS
- Centers for Medicare & Medicaid Services. *WISeR Model Webpage: Innovation Models». Retrieved September 2025, from https://www.cms.gov/priorities/innovation/innovation-models/wiser CMS
- Centers for Medicare & Medicaid Services. CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare. Press Release, June 27 2025. Retrieved from https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare CMS
- Centers for Medicare & Medicaid Services / Federal Register. Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model. Federal Register notice, July 1 2025 (Document 2025-12195). Retrieved from https://public-inspection.federalregister.gov/2025-12195.pdf public-inspection.federalregister.gov
FAQ
Q: What is the CMS WISeR Model?
A: The WISeR Model (Wasteful and Inappropriate Service Reduction) is a six‐year initiative by the Centers for Medicare & Medicaid Services (CMS) Innovation Center that tests the use of enhanced technologies (AI/ML) plus clinician review to reduce low-value, wasteful or inappropriate services in Original Medicare.
Q: Who are the CMS WISeR Model vendors (model participants) and what are their websites?
A: The model list of vendor participants (technology/clinical review firms) includes six companies, each assigned a state and MAC jurisdiction. Per CMS, they are:
- Cohere Health, Inc.
- Genzeon Corporation
- Humata Health, Inc.
- Innovaccer Inc.
- Virtix Health LLC
- Zyter Inc.
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