WISeR rules: decision times, UTN, resubmission and exemption

Decision time frames

The UTN (unique tracking number)

Non-affirmation, resubmission and appeal

Exemption (“gold card”) — Section 5, verbatim

Beginning in July 2026, CMS and WISeR Participants have implemented a process to automatically exempt individuals who are WISeR Providers or WISeR Suppliers from the prior authorization process and pre-payment medical review upon demonstration of compliance with Medicare coverage, coding, and payment rules. Participants grant exemption status at the individual provider National Provider Identifier (NPI) level, not the facility or organizational level. Providers and Suppliers who achieve exemption status are exempt for all lines of business (that is, Medicare Part A and Part B) for all WISeR Select Items and Services, across all sites of care. To achieve Exemption Status, a provider must do the following:

1. Submit at least 10 prior authorization requests across WISeR Select Items and Services during an exemption assessment period

2. Achieve a minimum prior authorization request affirmation rate threshold during an exemption assessment period. WISeR Participants have flexibility with designing their exemption programs, but all must apply the above minimal baseline parameters when determining exemption status. Additional Participant- specific criteria are publicly posted by the WISeR Participants. WISeR Participants also deliver provider education related to the Exemption Program. WISeR Providers and Suppliers will be added to the Exemption Status list on a quarterly basis. WISeR Participants will inform exempted providers and suppliers prior to the start of each quarter when they have been added to the exemption status list. The notification will specify the effective date of Exemption Status, the Exemption Status duration, and the process for reevaluating Exemption Status.

5.1 Claims Submissions for Exempted Providers When submitting claims for services furnished by exempted providers, the field in which the exempted provider's NPI must be submitted differs depending on the site of service. In the office and home settings, the exempted NPI should be included in the rendering provider field. In the ambulatory surgery center setting, the exempted NPI should be in the referring/ordering provider field. In the outpatient department setting, the exempted NPI should be in the operating provider field.

5.2 Reevaluation of Exemption Status Exempted WISeR Providers and Suppliers will maintain their status for at least a year (or longer per WISeR Participant discretion). WISeR Participants will reevaluate Exemption Status by issuing no more than 10 additional documentation requests (ADRs) per year, examining continued compliance with Medicare coverage criteria. After reevaluation is completed, WISeR Participants will notify any providers who lose Exemption Status at least 60 days before the start of the next quarter. The notification will include the effective date of removal and the process for re-earning Exemption Status.

WISeR Operational Guide v7.0, Section 5 · CMS document

Each participant’s affirmation-rate threshold

CMS sets the baseline (at least 10 requests and a minimum affirmation rate); each participant sets its own threshold. We show a number only where the participant or a source it cites has published one.