CMS Wasteful and Inappropriate Service Reduction (WISeR) Model Explained for Medicare Practices

The CMS WISeR Model lets you ask Medicare for approval before you do certain procedures for Original Medicare patients in six states. The six states are Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

You have two choices for each listed procedure.

• Ask for approval first: You send a prior authorization request before the procedure and get a decision back.
• Skip the approval step: You do the procedure and send the claim, and the claim gets a medical review before Medicare pays you.

Companies hired by CMS review each request using technology, including artificial intelligence (AI). Any request the company plans to turn down must first be reviewed by a human clinician. The WISeR program started on January 1, 2026 and runs until December 31, 2031. 

The WISeR start dates matter when you look back at older claims. According to the CMS FAQ, the reviewing companies use three key dates.

• January 5, 2026: Reviewing companies started accepting approval requests. 
• January 15, 2026: Procedures done on or after this date are part of WISeR. 
• Before January 15, 2026: Procedures done before this date are not part of WISeR.

So any procedure you did between January 1 and January 14, 2026 falls outside the WISeR program. 

To understand why CMS picked these specific procedures, it helps to first know what the WISeR Model is and how it changes Original Medicare.

What Is the CMS WISeR Model?

WISeR stands for Wasteful and Inappropriate Service Reduction. The WISeR Model is a six-year test run by the CMS Innovation Center. It adds prior authorization, which means getting approval before a procedure, to a short list of services in Original Medicare.

Prior authorization is new for Original Medicare. The lead author of the first study on WISeR points out that traditional Medicare had worked almost entirely without prior authorization, so WISeR is a major change in how older adults get care.

Every service on the WISeR list shares three traits. Each service: 

• can raise patient safety concerns when done without a real need 
• already has public Medicare coverage rules 
• may have a past record of fraud, waste or abuse

CMS built the list by reviewing Medicare coverage rules, medical research and reports from the HHS Office of Inspector General. Skin substitutes, knee arthroscopy for arthritis and electrical nerve stimulation are three examples on the list.

WISeR leaves several things unchanged for you and your patients.

• Your payment rate: Medicare pays you the same rate for these services.
• Coverage rules: WISeR does not change what Medicare covers. 
• Patient choice: Patients can still pick any Original Medicare provider they want.
• Coverage policies: Reviewers follow the same National Coverage Determination (NCD) and Local Coverage Determination (LCD) rules you already use.

The way the reviewing companies get paid worries many doctors. The CMS model page and the FAQ describe two sides of the payment setup.

• How companies earn money: Each company earns a share of the spending it helps Medicare avoid, and that share goes up or down based on its performance, including how providers rate their experience.
• How companies lose money: Companies are financially penalized when they turn down requests that should have been approved.

Because each company earns more when Medicare spends less, many doctors want to know how much control the AI has over each decision.

How Does WISeR Use AI in Medicare Prior Authorization?

In WISeR, AI can approve a request, but only a human clinician can turn one down. CMS wants the reviewing companies’ technology to approve requests automatically whenever it can, with most answers coming within 72 hours. However, a “no” works differently.

• A “no” is called a non-affirmation: It is CMS’s term for a decision that a planned procedure doesn’t meet Medicare’s rules.
• Technology cannot issue a non-affirmation alone: A human clinician with expertise in that type of care must review every non-affirmation.

CMS also built penalties into the reviewing companies’ pay to discourage wrong “no” answers. The CMS FAQ lists four safeguards:

• Audits: CMS audits each company’s decisions, and wrong decisions lower the company’s quality score and its pay. A company with too many wrong decisions can be removed from WISeR.
• Resubmission costs: Each company pays the cost of processing every request, including unlimited resubmissions after a “no.”
• One payment per patient: A company gets paid only once per patient, no matter how many times a request is resubmitted. 
• Lost payment after appeals: A company gets no payment, or has its payment taken back, when a “no” is followed by a successful claim appeal.

What Does the First Research on the WISeR Model Show?

The first published study on WISeR found that patients in the six WISeR states got fewer of the listed procedures soon after the program started. The JAMA study, written by Hannah Neprash and Michael Barnett, was published online on October 26, 2026. The researchers set up the study in three steps.

• Data source: They used Epic Cosmos, a health record database covering more than 300 million patient records across the country. 
• Comparison: They compared monthly use of WISeR services among traditional Medicare patients in the six WISeR states with use in all other states and the District of Columbia.
• Time period: They looked at the two years before WISeR began and the first six months after. 

Moreover, the study found a clear drop in the WISeR states compared with the rest of the country.

• Epidural steroid injections, the most common WISeR service, fell 15%. 
• Other WISeR services fell about 20%.
• Procedures CMS had planned for WISeR but never added showed no drop. The researchers say this suggests prior authorization itself caused the decline, not some other trend.

However, the study cannot yet tell whether the procedures patients didn’t get were needed. Lead author Hannah Neprash said the key unanswered question is whether the care patients didn’t receive was wasteful or necessary. The authors recommend future research on four points.

• Whether the drop in procedures lasts over WISeR’s six years 
• Whether patients are getting appropriate care 
• How WISeR affects patient health and doctors’ workload
• How WISeR affects Medicare spending

Will the WISeR Model Continue in 2027?

Yes. As of November 4, 2026, WISeR is set to keep running through 2027. The CMS FAQ, last updated September 22, 2026, says WISeR is a six-year model that started January 1, 2026 and will continue until December 31, 2031. Congress has tried to stop WISeR, but as of November 2026, no law ending it has been signed, and the program is still active. 

The challenge in Congress began with a ruling on how CMS launched WISeR. The GAO decision from the Government Accountability Office made two findings.

• WISeR counts as a rule: The notice CMS published to launch WISeR is a rule under the Congressional Review Act. 
• CMS skipped a step: Because WISeR is a rule, CMS should have sent it to Congress before it took effect.

That ruling allowed Congress to vote on ending WISeR. Two efforts followed, and neither one has stopped the program.

• Senate vote: The Senate voted 46 to 50 on a measure to end WISeR, so the measure failed.
• House funding bill: On June 9, 2026, the House Appropriations Committee approved its fiscal year 2027 health funding bill by a vote of 34 to 28. The bill includes language that would block HHS from spending money on WISeR or on any other model that adds prior authorization to traditional Medicare. 
• Where the funding bill stands: A CRS report from the Congressional Research Service says Congress has not passed the full-year 2027 health funding bill. Instead, the government is running on a temporary funding law through December 11, 2026. 

The WISeR spending ban only takes effect if two things happen. Congress must keep the WISeR language in the final 2027 funding bill, and that bill must become law. Until both happen, WISeR keeps running.

CMS has also said the WISeR rules themselves can change over time.

• More services could be added: CMS moved deep brain stimulation and percutaneous image-guided lumbar decompression to a later performance year, so either one could join the list.
• The operational guide gets updated: CMS says it will update the WISeR operational guide from time to time as the model runs. A new version can change codes, services or paperwork rules.

Keeping your WISeR workflow in place starts with knowing which reviewing company handles your state.

Which States Are in the WISeR Model, and Who Reviews Requests?

Six states are in the WISeR Model. The six states fall under four Medicare Administrative Contractor (MAC) regions, and CMS assigns one reviewing company to each state. 

A MAC is the company that processes your Medicare claims. A reviewing company is the company CMS hired to make WISeR approval decisions. 

State	Reviewing company	MAC and region
Arizona	Zyter	Noridian, JF
New Jersey	Genzeon	Novitas, JL
Ohio	Innovaccer	CGS, J15
Oklahoma	Humata Health	Novitas, JH
Texas	Cohere Health	Novitas, JH
Washington	Virtix Health	Noridian, JF

Your MAC matters as much as your state. According to Noridian guidance, an Arizona hospital that bills its claims to a MAC called WPS, instead of Noridian, is not part of WISeR. Only hospitals that bill WISeR services to Noridian are included. Before you change any workflow, confirm which MAC processes your claims.

The reviewing company’s portal is a separate system from your MAC’s portal. Noridian notes that WISeR is a model separate from the Noridian Medicare Portal, and that each reviewing company has its own portal.

The reviewing company is also your main contact for WISeR questions. CMS tells providers to contact the reviewing company assigned to their MAC region with questions. The WISeR help desk cannot support a company’s portal or check on a specific request. The operational guide lists phone numbers, emails, fax numbers and portal links for all six reviewing companies in section 3.3. Your state and MAC answer only half of the question of whether WISeR applies to you. The other half depends on your patient’s insurance. 

Who Does the WISeR Model Apply To?

WISeR applies to Original Medicare patients who get a listed procedure from a provider in one of the six WISeR states. CMS boils it down to two questions. 

• Do you practice in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington? 
• Will you provide at least one service from the WISeR list to an Original Medicare patient? 

If you answer yes to both questions, WISeR applies to you. 

The patient’s coverage decides the rest. 

Some providers and services are also left out of WISeR.

• Providers under special review: Providers under review by a Unified Program Integrity Contractor (UPIC) are excluded. 
• Certain types of care: Inpatient-only services, emergency services and any service that would put a patient at serious risk if delayed are excluded. 

Once the patient, state and provider qualify, the procedure decides whether a WISeR review is needed.

What Services Does WISeR Prior Authorization Cover?

WISeR covers 13 types of services. Appendix A of the operational guide lists the exact codes, using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. 

Service	What’s included
Knee arthroscopy for arthritis	CPT 29877
Trigeminal nerve destruction	CPT 64605 and 64610
Vagus nerve stimulation	CPT 64568, for listed diagnoses only
Phrenic nerve stimulator	CPT 33276 and 33277
Spinal cord stimulator placed through surgery	CPT 63655
Bladder control devices and slings	CPT 53440, 53445, 53451, 53452, 57288
Sacral nerve stimulation	CPT 64581, or 64561 billed with 64590
Penile implant	CPT 54400, 54401, 54405
Vertebroplasty and kyphoplasty	Codes in Appendix A
Epidural steroid injections	CPT 62323 when used for the injection
Cervical (neck) fusion	CPT 22554
Hypoglossal nerve stimulation for sleep apnea	Codes in Appendix A, including newer HCPCS codes
Skin substitutes for leg and foot ulcers	Diabetic and venous ulcers, in four states

All of these codes come from Appendix A of the guide, current as of July 24, 2026. 

CMS planned two more services for WISeR but delayed both.

• Deep brain stimulation: The first stage of the procedure is on Medicare’s inpatient-only list, and WISeR excludes inpatient-only care. CMS will reconsider adding it in a future performance year.
• Percutaneous image-guided lumbar decompression: This procedure is part of several CMS-approved clinical studies, which makes adding it harder. CMS will also reconsider it in a future performance year. 

Skin substitutes depend on where you work. They are not part of WISeR in Noridian’s JF region, because the coverage rule there was withdrawn. Wound clinics in Arizona and Washington follow their usual skin substitute process. Wound clinics in New Jersey, Ohio, Oklahoma and Texas go through WISeR.

Some well-known codes stay in a different CMS program. WISeR does not overlap with Medicare’s existing prior authorization program for certain hospital outpatient services. CPT 63650 for spinal stimulators placed through the skin, and CPT 22551 and 22552 for neck fusion, stay in that older program.

Device trials follow their own rule.

• Only the permanent implant is reviewed: For treatments that start with a trial, WISeR reviews only the permanent implant. The trial still has to be done, and its results go with the permanent request.
• How the codes signal a permanent implant: CPT 64561 for sacral nerve stimulation needs review only when billed with CPT 64590, which marks a permanent device. 
• Lead replacements: A lead replacement billed under CPT 64561 does not need WISeR review. 

The service list changes often. The guide reached version 7.0 on July 24, 2026. Earlier updates in February, March and April 2026 removed codes, added new hypoglossal nerve stimulation codes and changed the paperwork rules for epidural steroid injections. CMS says it can update the service list during the model’s run. Check the version number on the guide each time you look up a code. The service name tells you whether a procedure might be on the list, but the exact code decides whether it is. 

How Do You Check If a Procedure Falls Under WISeR?

To check whether a procedure falls under WISeR, use the appendices at the back of the current operational guide. Appendix A lists the main codes. Appendix B lists the diagnosis codes, known as ICD-10 codes, that narrow some services. Appendix C lists related codes. CMS switched the contents of B and C starting in version 4.0. Many older articles, and even the CMS FAQ, still use the old letters, so read the appendix title before you trust it.

The diagnosis code can take a procedure off the list. For services that have a diagnosis list, a procedure billed without one of those listed diagnosis codes is outside WISeR. Vagus nerve stimulation, sacral nerve stimulation and skin substitutes all work this way.

Related codes depend on the main procedure. They don’t need their own approval. They get paid when the main procedure is approved, and they get denied or taken back when it isn’t. Anesthesia, implanted devices, doctor services and facility services all count as related codes. That means the anesthesiologist’s payment depends on the surgeon’s request.

Where you do the procedure decides which claim gets reviewed. WISeR covers hospital outpatient departments, surgery centers, the patient’s home and the doctor’s office. In hospital outpatient departments and surgery centers, Medicare reviews the facility’s claim. Before you schedule, go through this checklist.

If everything checks out, you have two ways to handle the procedure.

Should You Request WISeR Prior Authorization or Use Prepayment Review?

You can ask for WISeR approval before the procedure, or you can do the procedure first and let Medicare review the claim before paying. That second option is called prepayment review. 

Asking first is optional. However, if you send a claim with no approval decision on file, the MAC holds the claim and sends it to the reviewing company. Either way, someone reviews it.

Question	Ask first	Review before payment
When is it reviewed?	Before the procedure	After the procedure
What do you send?	Request and patient records	Records when they’re requested
When do you know if you’ll be paid?	Before treatment	After treatment
What gets delayed?	The appointment	Your payment
What do you track?	Decision and tracking number	Records request and claim status

Prepayment review has a firm deadline. You don’t add anything special to the claim. The reviewing company sends a records request, and you have 45 days to answer. For surgery centers and hospital outpatient departments, the request goes to the facility, not the doctor. The company decides within 3 days of getting all the records, and if you don’t answer, the claim is denied.

Asking first makes payment more predictable, but it isn’t a promise. An approved claim will likely be paid if everything else is correct, and it gets some protection from later audits. It can still be denied for billing mistakes, or if new information comes up that would have changed the answer. On either path, your paperwork decides the outcome.

What Documentation Does WISeR Prior Authorization Require?

A WISeR request needs basic patient and provider details plus medical records that fit the procedure. CMS says WISeR doesn’t add new paperwork, because everything it asks for is already required for Medicare payment. The difference is that you send it before the procedure. 

Missing basic details cause a lot of delays. Each request needs the patient’s name, Medicare Beneficiary Identifier (MBI), date of birth and address. It also needs the facility and doctor’s names and addresses, their National Provider Identifier (NPI) numbers, and their Provider Transaction Access Number (PTAN), with the facility’s CMS Certification Number where it applies. It also needs the codes, the expected location, the number of services planned within 120 days, and whether it’s a first request, a resubmission or urgent. It helps to give each item an owner.

Each service also has its own medical proof. Section 6 of the guide lists it, and your National Coverage Determination (NCD) or Local Coverage Determination (LCD) adds details. These are the items reviewers most often want to see.

Service	What reviewers look for
Epidural steroid injection	Pain lasting at least 4 weeks, plus proof the patient couldn’t tolerate conservative care or that 4 weeks of it didn’t help. Also a pain or function score at the first visit, repeated at each follow-up, no more than four sessions per spine area in 12 months, and an active exercise or rehab program
Spinal cord stimulator	At least one failed treatment, a team evaluation that includes a psychological review, a trial that lowered pain and improved function, and the reason leads can’t be placed through the skin
Knee arthroscopy	Early or milder arthritis with symptoms like locking or catching on top of pain, plus standing x-rays and MRI results
Skin substitutes	Starting wound size and location, a wound at least 1.0 square cm, an ankle-brachial index of at least 0.60 or toe pressure above 30 mmHg, and no more than 10 applications in 12 weeks
Hypoglossal nerve stimulation	Age 22 or older, body mass index under 35, a sleep study within 24 months showing 15 to 65 breathing events per hour, and a sleep endoscopy result
Vertebral augmentation	A pain score of 5 or more for outpatients or 8 or more for hospital patients, plus a referral for a bone density check

These requirements come from version 7.0 of the guide and the coverage policies it points to. A complete file is easier to review, which brings up how long a decision takes.

How Long Does WISeR Prior Authorization Take?

CMS expects WISeR reviewing companies to decide a regular request within 3 calendar days and an urgent request within 2 calendar days. The operational guide says reviewing companies plan to decide within 3 calendar days of receiving a first request or a resubmission, and within 2 calendar days for an urgent request. CMS’s performance measures explain how those days are counted. 

• The day the request arrives counts as day 1: A request received on January 1 and decided on January 3 meets the 3-day standard. 
• A decision on day 4 is late: A request received on January 1 and decided on January 4 misses the standard.

A request only gets the 2-day urgent timeline if the reviewing company agrees it’s urgent.

• What counts as urgent: A delay could seriously harm the patient’s life, health or ability to fully recover.
• If the company disagrees: The company moves the request to the regular 3-day timeline and tells you about the change.
• How often urgent requests happen: WISeR only covers non-emergency services, so CMS expects urgent requests to be rare.

Actual wait times in WISeR’s first months were much longer than CMS’s deadlines. A snapshot report from Senator Maria Cantwell’s office shared two findings from Washington state.

• University of Washington Medical System: As of April 20, 2026, both urgent and regular decisions took an average of 15 to 20 days.
• Washington State Hospital Association survey: As of April 17, 2026, procedures that used to be approved in about 2 weeks were taking 4 to 8 weeks. 

Washington wasn’t the only state with early problems. FOIA records that the Electronic Frontier Foundation obtained from CMS show two things.

• Problems at four of six companies: CMS sent requests for information or corrective action to four of the six reviewing companies within WISeR’s first three months.
• One request waited 83 days: A status report in the records shows one prior authorization request that went unanswered for 83 days.

CMS then took action against Virtix Health, the reviewing company for Washington, and Virtix’s turnaround times improved.

• June 23, 2026: CMS sent Virtix a corrective action plan because it wasn’t meeting the required turnaround time.
• Closer oversight: CMS audited Virtix in five areas, including how its portal worked, and set up meetings every two weeks to track its progress.
• August 14, 2026: Virtix says the corrective action plan was closed on this date. It also reports average turnaround of 1.18 days for prior authorization and 1.17 days for prepayment review. CMS confirmed that Virtix cut its turnaround times and that the plan was closed.

The 1.18-day and 1.17-day figures are averages, and Virtix reported them itself. Some requests will still take longer. Give yourself a few days of buffer before each procedure date, and log every request so you can spot one that’s running late.

Check who on your team can see each request in the portal. As of April 2026, Washington hospitals said Virtix’s portal let only the person who submitted a request see its updates and documents, so coworkers couldn’t follow the case when that person was out. 

Whatever state you’re in, ask your reviewing company how several staff members can see the same request. When the decision comes back, it includes a tracking number that your claim needs. 

What Do WISeR Decisions and the Tracking Number Mean for Your Claim?

Each WISeR request gets a Unique Tracking Number (UTN) from the MAC, and the UTN goes on your claim if you do the procedure, whether the answer was yes or no. Every request ends in one of four decisions.

The partial affirmation decision started on April 1, 2026. The reviewing company also sends the patient a copy of each decision. Your patient may call about a decision letter before your staff have seen it, so make sure your front desk knows how to answer. 

The UTN can arrive after the decision. The MAC creates each UTN, so you may get the decision first.

• For a regular request: Wait for the UTN. Don’t send the request again while you wait. 
• For an approved urgent request: Hold the claim until the UTN arrives, so the claim isn’t denied. 

A UTN is valid for a limited time.

• 120 calendar days: The UTN is valid for 120 calendar days from the decision date. An approval dated January 5, 2026 covers procedures done through May 4, 2026. 
• Repeat treatments: For services given more than once, such as skin substitute applications, use the same UTN on each claim during the 120 days.
• Past 120 days: If the procedure moves past the 120-day window, you need a new request and a new UTN. 

Where the UTN goes depends on the type of claim.

• Electronic professional claim (837P): Put the UTN in loop 2300, in the REF segment with qualifier G1. A UTN there applies to the whole claim unless a different UTN is entered on a service line in loop 2400.
• Paper CMS-1500 form: Put the UTN in the first 14 positions of item 23.
• Facility claims: Facility claims can carry no more than one UTN. 
• Hospital outpatient departments and surgery centers. The UTN goes on the facility claim. If a hospital outpatient department will bill several approved services on one claim, all of those services must be on the same request and share one UTN.

For procedures done in a facility, the physician can send the request. CMS allows a physician to submit the request on behalf of a facility. The physician puts their own contact details on the cover sheet along with the facility’s, and gets a copy of the decision from the facility. CGS tells providers to submit one request for the facility when a WISeR service is scheduled in a surgery center or hospital outpatient department. The UTN matters most when the answer is no. 

What Should You Do After a WISeR Non-Affirmation?

A WISeR non-affirmation means the reviewer found that the request likely doesn’t meet Medicare’s rules. The reviewing company must list every missing or noncompliant item behind the decision and explain how to resubmit. Work through the letter step by step.

A resubmission has to match the first request exactly.

• No limit on tries: You can resubmit as many times as you need.
• Exact match: Each resubmission must include the original UTN, and the patient’s first name, last name and date of birth must match the first request exactly. 
• Peer-to-peer call: You can ask to speak with a clinician who has expertise in that specialty. The resubmission still follows the same 3-day or 2-day timeline. 

A non-affirmation itself can’t be appealed.

• Why: A non-affirmation isn’t a decision on a claim, so it carries no appeal rights. 
• When appeal rights start: If you do the procedure and send the claim anyway, the MAC denies the claim, and that denial opens your appeal rights.
• When resubmitting ends: You can keep resubmitting only until the claim has been sent and denied. 

Before you bill a procedure that got a no, decide whether resubmitting or appealing is the better route.

If the patient still wants the procedure, protect them from a surprise bill.

• Medical necessity no: Give the patient an Advance Beneficiary Notice of Noncoverage (ABN) before the procedure if you expect Medicare won’t pay, and add the GA modifier to the claim. 
• Purely cosmetic services: The ABN is voluntary, but CMS encourages it. Add the GX modifier to the claim. 

CMS keeps the current notice forms on its ABN forms page.

Every approval you earn also counts toward skipping WISeR reviews altogether.

How Does WISeR Gold Carding Work?

WISeR gold carding lets doctors with a strong approval record skip WISeR reviews, and it started in July 2026. Each doctor earns the exemption on their own National Provider Identifier (NPI), never at the facility or group level. The exemption covers Part A and Part B claims for every WISeR service in every location. One surgeon in your group can qualify even if the others haven’t yet.

Each reviewing company designs its own program on top of those two requirements and posts its extra criteria publicly. Check your state’s reviewing company for its exact approval rate. 

The exemption follows a set schedule.

• Added quarterly: Reviewing companies add doctors to the exemption list each quarter and notify them before the quarter starts. The notice gives the start date, how long the exemption lasts and how it will be rechecked. 
• At least one year: An exemption lasts at least a year, or longer if the reviewing company chooses. 
• Rechecks: The reviewing company can request records up to 10 times a year to recheck the exemption. A doctor who loses it gets notice at least 60 days before the next quarter starts. 
• No requests needed An exempt doctor shouldn’t send WISeR requests. Requests from exempt doctors are dismissed. 

Exempt claims need the doctor’s NPI in the right field, and the field depends on where the procedure happens.

• Office or home: Put the NPI in the rendering provider field. 
• Surgery center: Put the NPI in the referring or ordering provider field. 
• Hospital outpatient department: Put the NPI in the operating provider field.

Each decision letter covers only one request. To know which doctors are close to qualifying, keep your own count of each doctor’s requests and approvals. Every avoidable dismissal slows that progress.

Which WISeR Mistakes Lead to Dismissals?

A WISeR dismissal means the request was never reviewed. A request is dismissed when required details are missing or wrong, when the service isn’t part of WISeR, or when the request is a duplicate. Dismissed requests are never reviewed for medical necessity. To fix a dismissal, follow two steps. 

• Resend everything: Correct the error and send the request again with all of the original documents. 
• Keep the same request type: If the dismissed request was a first request, mark the new one as a first request too. 

CMS lists these common dismissal reasons and how to handle each one.

CMS counts a request as a duplicate when the same provider sends a new request for the same patient and service before the first request is decided. Clear ownership of each step helps prevent errors like these.

How Should Your Practice Prepare for the WISeR Model?

To prepare for WISeR, give each step one owner and a clear sign that the step is finished.

Partner facilities need a plan too. For procedures in hospital outpatient departments and surgery centers, agree with each facility on three points.

• Who sends the request: The physician’s office or the facility
• Who receives the decision and UTN: And how both reach the other side before the procedure date
• Who answers records requests: If the claim goes to prepayment review, the records request goes to the billing facility, even when the physician sent the original approval request. 

A shared tracking log keeps every request visible.

Column	Why it helps
Internal patient or visit ID	Identifies the case without exposing the MBI
Doctor’s NPI	Counts requests toward the exemption
Procedure date	Connects the request to the schedule
Procedure and diagnosis codes	Confirms the request belongs in WISeR
Reviewing company and submission method	Shows whether the 72-hour limit applies
Date sent and follow-up date	Flags requests that are running late
Decision and UTN	Connects the request to the claim
UTN expiration date	Prevents procedures after day 120
Final claim status	Shows whether the approval led to payment

Keep the log inside your secure practice software. A spreadsheet with patient details on a shared drive is a privacy risk.

Your electronic health record (EHR) decides how easy the second question is to answer. When pain scores, wound sizes, trial results and sleep study numbers are saved in set fields, staff can pull what reviewers want in minutes instead of searching long notes. Linking the approval to the visit and the claim keeps the UTN with the right bill. Software helps with this work, but your practice is still responsible for meeting Medicare’s rules. 

At OmniMD, our EHR, practice management and medical billing software share one patient record, so doctors, authorization staff and billers work from the same note, decision and claim.