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CGS PAR 457: WISeR Model Prior Authorization (Ohio)

CMS's Wasteful and Inappropriate Service Reduction (WISeR) Model requires prior authorization for selected services, such as skin and tissue substitutes, electrical nerve stimulator implantation and knee arthroscopy for osteoarthritis, for Original Medicare patients in participating states. In Ohio, physician offices, hospital outpatient departments and ASCs use this CGS form, and the model participant Innovaccer reviews the request and issues the decision.

Who completes it

Staff at the rendering physician's office, hospital outpatient department or ASC complete it: place of service, up to four CPT or HCPCS codes, the facility or group practice, the beneficiary, and the attending or rendering physician, with clinical records attached.

Submitting and payment

How to submit it
Send it to CGS through myCGS, fax or mail, or directly to Innovaccer through esMD, the Innovaccer WISeR portal or fax. Requests opened January 5, 2026, for dates of service from January 15, 2026.
Who pays
If a WISeR service is billed without prior authorization, CGS suspends the claim for Innovaccer's prepayment review, and records are due within 45 days of the documentation request.

Good to know

  • The model runs from January 1, 2026, to December 31, 2031, in Ohio, New Jersey, Oklahoma, Texas, Arizona and Washington, each state with its own technology participant.
  • Decisions and UTNs are valid for 120 calendar days from the decision date, and providers may resubmit an unlimited number of times for each request.
  • Covered settings include hospital outpatient departments, ASCs, physician offices and the patient's home. The full list of services and codes is in the appendices of the CMS WISeR operational guide.
  • Veterans Affairs, Indian Health Service and Medicare Advantage claims, Part A/B rebilling and emergency department services are excluded from WISeR review.

Get the official form

Download the current version from the source each time; forms change without notice.

Implementation of Wasteful and Inappropriate Service Reduction (WISeR) Model Prior Authorization

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who reviews WISeR prior authorization requests in Ohio?

Innovaccer, the WISeR participant for Ohio. It processes requests, issues decisions and UTNs, and performs prepayment review of claims billed without prior authorization. CGS receives submissions sent to it, forwards them to Innovaccer, and processes claims based on Innovaccer's decisions.

What happens if a WISeR service is billed without prior authorization?

CGS suspends the claim and forwards it to Innovaccer, which mails an Additional Documentation Request letter with a barcode. Records are due within 45 days. If the claim denies for non-receipt of records, the provider files a redetermination, the first-level appeal, rather than a reopening.

How long is a WISeR prior authorization decision valid?

Decisions and their UTNs are valid for 120 calendar days from the decision date. Providers may resubmit an unlimited number of times for each request, entering the UTN of the most recent submission on PAR 457.