The Question · Hospital · Original Medicare

WISeR reviews your facility claim. The gold card belongs to the physician.

Since January 2026, Original Medicare requires prior authorization or prepayment review for selected outpatient services in six states. For hospital outpatient departments, the review lands on the facility claim. The exemption that ends it is earned one physician NPI at a time.

By ASP-RCM Editorial, Healthcare RCM Practice · Updated November 4, 2026

The question we asked on LinkedIn

Under WISeR, your outpatient facility claim is reviewed, but gold card exemptions go to individual physician NPIs. Who in your hospital is tracking which surgeons have one?

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States in WISeR

Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, January 1, 2026 to December 31, 2031

3 days

Typical determination time

2 days for expedited requests. Requests routed through the MAC may take longer than 72 hours.

Requests to qualify for a gold card

Minimum prior authorization requests per NPI across WISeR services

90%

Highest allowed affirmation bar

Participants may set the exemption threshold lower, never higher

The WISeR service list and its status

From the July 2025 notice (90 FR 28749) and the April 6, 2026 delay notice. Inpatient-only services and emergency services are excluded.

Service	Coverage policy	Status, Nov 2026
Electrical nerve stimulators	NCD 160.7	Active
Sacral nerve stimulation for urinary incontinence	NCD 230.18	Active
Phrenic nerve stimulator	NCD 160.19	Active
Vagus nerve stimulation	NCD 160.18	Active
Induced lesions of nerve tracts	NCD 160.1	Active
Epidural steroid injections for pain (not facet joint injections)	LCDs	Active
Percutaneous vertebral augmentation for compression fracture	LCDs	Active
Cervical fusion	LCDs	Active
Arthroscopic lavage and debridement, osteoarthritic knee	NCD 150.9	Active
Hypoglossal nerve stimulation for sleep apnea	LCDs	Active
Incontinence control devices	NCD 230.10	Active
Diagnosis and treatment of impotence	NCD 230.4	Active
Skin and tissue substitutes, lower extremity wounds	LCDs L35041, L36690	Active where the LCD applies
Deep brain stimulation	NCD 160.24	Delayed until a future notice
Percutaneous image-guided lumbar decompression	NCD 150.13	Delayed until a future notice

Check Appendix A of the current WISeR Provider and Supplier Operational Guide for codes; CMS can change the list.

How a WISeR service moves through a hospital outpatient department

CMS says that for HOPD and ASC services, prior authorization and prepayment review apply to the facility claim.

Order and request
Request goes to the state's WISeR participant portal or through the MAC, with codes, diagnosis and clinical records.
Determination
Affirmed or non-affirmed, typically within 3 days. The decision carries a unique tracking number (UTN).
Facility claim
The UTN goes on the claim. Associated codes are paid only if the primary code is affirmed.
No request filed
The claim goes to prepayment medical review, for dates of service from January 15, 2026. Records must be sent before payment.

Prior authorization or prepayment review

Hospitals can choose either path. Only one of them tells you the answer before the patient is on the table.

Skip the request, take prepayment review

Service is done before anyone knows if it meets the NCD or LCD
Cash waits on a records request after the claim drops
Associated codes are recouped if the primary code is denied
Nothing counts toward the physician's gold card

Request prior authorization

Decision and UTN in hand before the date of service
Non-affirmation can be fixed and resubmitted before care
Coverage question settled before the procedure
Each request counts toward the 10-request gold card minimum

Gold card rules every hospital should know

From the CMS WISeR exemption status program fact sheet. The program began July 2026.

Granted per NPI

Exemption is earned by the individual physician, not the hospital or the group. Your facility claim benefits only when that physician's NPI is exempt.

Checked every quarter

Participants evaluate quarterly and tell providers before the quarter starts. Status lasts at least one year once earned.

All sites, Part A and B

An exempt NPI is exempt for all WISeR services across all sites of care. Re-evaluation uses no more than 10 record requests a year.

WISeR so far

Jul 1, 2025
CMS notice (90 FR 28749) announces the six-year model.
Jan 1, 2026
Prior authorization starts in the six states.
Jan 15, 2026
Prepayment review applies to claims with no request.
Apr 6, 2026
Two services delayed: deep brain stimulation and lumbar decompression.
May 12, 2026
GAO rules the WISeR notice is a rule under the Congressional Review Act.
Jul 2026
Gold card exemption program begins.
Dec 31, 2031
Model ends unless CMS changes it.

Is your hospital WISeR-ready?

For hospitals with outpatient departments in the six states.

We know which of our scheduled procedures fall under WISeRScheduling checks for a UTN before the date of serviceThe UTN is on every facility claim for a WISeR serviceWe track non-affirmations by physician and by reasonWe know which of our physicians hold a gold card this quarterPrepayment record requests have an owner and a turnaround targetWe check for recoupment of associated codes after a denialOur MA and Original Medicare authorization worklists are separate

0 of 8Under 6? WISeR is likely holding outpatient cash you have not counted.Get a free outpatient denial audit

TAKEAWAY

WISeR reviews the facility claim but rewards the physician. Request authorization instead of taking prepayment review, put the UTN on every claim, and track gold card status by NPI every quarter.

Questions operators ask next

Does WISeR apply to hospital outpatient departments?

Yes. CMS says hospital outpatient department, ambulatory surgery center, office and home claims are in scope in the six WISeR states. For HOPD and ASC services, prior authorization and prepayment review apply to the facility claim. Inpatient-only services and emergency services are excluded, and the model does not apply to Medicare Advantage enrollees.

What happens if we do not request prior authorization under WISeR?

The claim is subject to prepayment medical review for dates of service from January 15, 2026. Medical records must support the NCD or LCD before payment. CMS says associated codes are paid only if the primary code is affirmed, and are recouped if it is denied. All existing appeal rights remain.

How does a provider get a WISeR gold card?

Each WISeR participant runs an exemption program within CMS baseline rules. Exemption is granted to individual NPIs that submit at least 10 prior authorization requests and meet an affirmation threshold no higher than 90% during an assessment period of up to one year. Status is reviewed quarterly and lasts at least one year.

Which states and services are in the WISeR model?

Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, from January 1, 2026 through December 31, 2031. Services include nerve stimulators, epidural steroid injections, cervical fusion, knee arthroscopy for osteoarthritis, vertebral augmentation and skin substitutes. Deep brain stimulation and lumbar decompression were delayed in April 2026.

Find out where WISeR is holding your outpatient cash

Send us your WISeR requests, non-affirmations and prepayment review letters since January. A senior hospital revenue cycle lead maps where facility claims stall, in a free 30-minute call with a written gap report after.

Get a free outpatient denial audit Book a 30-minute call

Keep reading

Hospital revenue cycle management Prior authorization command center CMS-0057-F prior authorization API deadline Medicare Advantage two-midnight rule and inpatient downgrades All questions in The Question series

Sources

Checked November 4, 2026. WISeR participants publish their own portals and exemption criteria within CMS rules; confirm current codes in the Operational Guide. General information, not legal advice.