Providers

Frequently Asked Questions

Getting Started & Provider Enrollment

What is WISeR?

WISeR is a Centers for Medicare & Medicaid Services (CMS) Innovation Center model that aims to improve care quality while reducing unnecessary or unsupported services in Medicare Fee-for-Service (FFS) through AI-enabled prior authorization and pre-payment medical review. The model leverages enhanced technology to streamline the prior authorization process for a specific list of items and services, with a goal of promoting high-value, evidence-based care.

Which technology vendor is participating in WISeR for Oklahoma?

Humata Health is the designated WISeR Model Participant for Oklahoma, leading efforts to support Medicare providers with prior authorization and pre-payment medical review. As a physician-led company, Humata Health is solely focused on solving the complexities of prior authorization. By seamlessly connecting payers and providers, we leverage deep clinical expertise and advanced AI to streamline approvals, reduce administrative burden, and ensure patients receive timely care.

When and where will WISeR be implemented?

The WISeR model is set to run for six performance years, spanning from January 1, 2026, to December 31, 2031. It will be implemented in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Providers can begin submitting prior authorizations on January 5, 2026.

Which Medicare beneficiaries does WISeR include?

The WISeR model applies to Medicare fee-for-service beneficiaries who are eligible for Medicare Part A and enrolled in Medicare Part B at the time of the prior authorization request or on the date of service for the claim subject to pre-payment review and:

Aged 18 years or older
Not enrolled in Medicare Advantage
Have Medicare as the primary payer
Not covered under the United Mine Worker Health and Retirement Funds

Do providers need to create an account prior to prior authorization portal submission?

Yes. Provider registration is required to create an account before submitting prior authorization requests through the Humata Health submission portal the WISeR Model. Account creation is now available on the Humata WISeR Portal

Can I share portal access with others and is there administrative portal access?

Logins are linked to individual email addresses and may not be shared. To request access for another user, please contact wiser.support@humatahealth.com. Administrative access is not available at this time, but is planned as an enhancement in January.

What is the function of the Manage Providers tab?

Adding providers under Manage Providers enables autopopulation of demographics for future PA requests and avoids manual entry.

What items and services are covered under WISeR?

For the most up-to-date list of criteria and codes, please visit the CMS WISeR Model Overview web page.

Which places of service are impacted?

The WISeR model applies to providers billing to Part B claims with a place of service (POS) office (11), home (12), ambulatory surgical center (24), and Part A outpatient claims with type of bill (TOB) 13X. POS 19 and POS 22 are not included as they are associated with claims processing, not with PA.

The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed. However, a provider or supplier may request an expedited review, if needed.

Will WISeR change Medicare coverage or payment rules?

No. WISeR does not alter existing Medicare FFS coverage, payment, or appeals policies — it enhances review efficiency, transparency, and decision accuracy.

Will there be education sessions?

Yes. Joint provider education sessions with Novitas are planned. Dates, registration links, and materials will be posted on the Novitas web page.The first Novitas and Humata-Led Educational Session & Portal Training held December 12th, 2025 is live and available for review. The next webinar is scheduled for January 7th, 2026 and is now open for registration Novitas Event Registration

Where can I learn more about the WISeR model and the services included?

You can learn more on the WISeR model as through the CMS WISeR Model Overview and Novitas Solutions WISeR Resources web pages.

Submissions, Authorizations and Workflow

What is the recommended submission channel?

The Humata WISeR Portal (account creation is now available for portal submissions beginning January 5th, 2026) is recommended for the best provider experience. The portal will allow prior authorization submissions, relevant criteria visualization with a list of clinical information needed for review, and a dashboard with PA status and determination letters. Fax and mail are available submission methods; however, the portal provides the fastest turnaround and decision times.

Future integrations with providers will enable near-instant decisions for prior authorization with a significant reduction in administrative burden. If you are a provider in Oklahoma impacted by WISeR, let us know if you would be interested

Do fax/mail submissions require a coversheet?

Yes, a fillable PA or ADR coversheet must be the first page. Coversheets available for download starting Jan 1, 2026 at https://www.humatahealth.com/

How does WISeR impact my workflow?

Option 1 – Prior Authorization (recommended)

Submit through the Humata WISeR Portal (or approved Medicare channels such as Novitas MAC portal, fax, or mail).
Determinations are typically issued within three business days (two if expedited).
Outcomes include Provisional Affirmation (valid 120 days) or Non-Affirmation (with resubmission guidance).

Option 2 – Pre-Payment Medical Review (default if no prior authorization)

Provider submits claim to the MAC post service. The claim will be suspended for clinician review prior to payment, increasing cycle time and administrative effort. The provider has 45 days to respond to the ADR letter request for clinicals.
Standard Medicare claim and appeals processes apply through the MAC.

What if multiple codes map to different NCD/LCD criteria?

Please submit a separate PA for each criteria set/policy; only one UTN can be assigned to each NCD/LCD decision.

Decisions, Resubmissions & Appeals

Can I resubmit a prior authorization and how can a provider appeal a decision?

Yes. Providers may resubmit within 120 days of the original decision.

For a “non-affirmed” prior authorization request — meaning that a future service was found not to meet Medicare coverage, coding or payment requirements — the provider/supplier has unlimited opportunities to resubmit a request. A non-affirmed decision does not prevent the provider/supplier from delivering the service and submitting a claim. Submission of such a claim and denial by the MAC will constitute an initial payment determination, which would be subject to the existing administrative appeals processes available to providers, suppliers and people with Medicare.

Is a resubmission considered a new prior authorization request?

An initial prior authorization request is the first submission sent to the WISeR participant for review and decision. If that request is non-affirmed, the provider may submit a subsequent request (also called a resubmission) with additional or updated documentation to address the errors or omissions identified during the initial review.

If the clinical information changes from the original request, it is considered a new prior authorization submission rather than a resubmission.

When requesting a Peer-to-Peer (P2P) via mail or fax upon a valid resubmission, ensure this option is selected on the P2P coversheet and that the toggle button is enabled if requesting through the portal.

What is an Additional Documentation Request (ADR)? How do I respond to an ADR?

A letter/request sent to the provider for medical records to support Medicare coverage/medical necessity review.

Portal: enter claims ID + Medicare Beneficiary ID, upload clinicals, review & submit, track on dashboard. Providers have 45 days to submit all clinical documentation and no response results in an auto-denial.

Who do I contact if I have questions related to the Humata portal or clinical review
process?

For general and technical support, please email the following: wiser.support@humatahealth.com.

Oklahoma Provider WISeR Resources

Quick Access

Important Dates

Cover Sheets

Frequently Asked Questions