WISeR in Practice: Pre + Live Webinar Q&A
Virtix Health recently hosted “WISeR in Practice: What Washington Physicians and Providers Need to Know,” an insightful and practical webinar focused on the CMS WISeR (Wasteful and Inappropriate Service Reduction) Model, tailored specifically for physicians, providers, and their staff in Washington state. The session aimed to clarify important aspects such as submission requirements, determination timelines, and guidance on handling potential issues.
Given the high level of engagement, please find full list of questions asked during the webinar below to serve as a helpful resource for Washington State healthcare professionals navigating the WISeR program.
If you have a question regarding the Virtix Health WISeR Provider Portal that is not covered below, we’d love to hear from you. Please complete the form and submit your question here [link to form below].
Pre-Webinar Q&A
Are both Part A and Part B Medicare following this requirement or is it only for Part A claims?
Virtix Health
All items and services within the scope of WISeR are subject to this process whether it’s Part A or B claims
Can you walk through the portal and peer to peer request also helpful?
Virtix Health
Hopefully the webinar answered these questions, please reach out to our customer support if you have any remaining questions.
What is being done to improve the authorization workflow? Not too long ago, there was a push to reduce administrative burden through simplification, and this has been the complete opposite, creating a strain on resources and we are an academic health system.
Virtix Health
We are open to suggestions as to what would make this process easier for you. We are meeting our TAT requirements and often issuing affirmations the same day as submission.
How do we connect with a supervisor regarding feedback on this program and how it is negatively impacting provider practices, delaying patient care and causing a large admin burden.
Virtix Health
Please reach out to our Customer Support team, as they can assist with escalating your concerns to a supervisor as needed.
What information is Virtix willing to share on denials to show proof that an appropriate peer to peer human physician has been involved in the decision? We suggest name, NPI, specialty and date/time reviewed.
Virtix Health
Our peer to peer process are live interactions. Providers are welcome to ask our physicians for their background and specialty
Does outpatient therapy require prior authorization specifically in Washington state region?
Virtix Health
Please see our FAQ that indicates which products and services are in the scope of WISeR. https://virtixhealth.com/wiser/FAQ/
1) why isn’t the UTN included with affirmation letter?
2) Why do I have to resubmit EVERYTHING when I do a resubmission?
3) Why can’t everyone in my team see all submissions?
4) Why can’t we be notified of decisions via fax or email?
5) Why can’t we “edit” dismissed requests, especially when it’s for something simple like a missed dx code or incorrect ID #?
6) why can’t we organize our submitted requests so we can see easily the affirmed/non-affirmed/dismissed cases?
7) why can’t patient names be easily seen on the case list?
Virtix Health
- Virtix includes the UTN in the affirmation letter once Noridian has issued the UTN. To not delay care, CMS has advised WISeR Model Participants to share outcomes even before UTN issuance.
- We are currently testing a new enhancement to pull previous case information and clinical documentation forward into a resubmission. This feature will also allow you to copy information to build a new case for the Beneficiary.
- Case sharing is now available.
- CMS has requested that our decisions are provided back the same way they were received (fax to fax, portal to portal, mail to mail, etc.)
- Dismissed cases are recorded for reporting purposes. Please refer to number 2 as this enhancement will address this concern.
- You have the sort capability at the top of each column. However we are looking at enhancing this feature.
- Similar to 6, we are always looking to enhance the usability of the portal.
We have issues with the UTN number being assigned to approved cases. Is that being resolved?
Noridian
We would need an example to review.
Are any of the “select” Medicare procedures for ENT physicians & providers?
Virtix Health
Please see our FAQ that indicates which products and services are in the scope of WISeR. https://virtixhealth.com/wiser/FAQ/
64590 what documentation needs to be submitted?
Virtix Health
Please submit documentation which meets NCD 230.18 coverage criteria. Please note that 64590 is an associated code within the WISeR scope of services.
Is there a way to identify our performance data (approvals/denials) on an ongoing basis?
Virtix Health
We are evaluating reporting options. This will need to be approved by CMS.
How long are authorization vailid for?
Virtix Health
120 days
Are all retro authorizations being denied.
Virtix Health
We evaluate prior authorizations, if you’ve performed the procedure and are seeking authorization after the fact, it would be dismissed. You would need to submit the claim for a prepayment review
i still can not access the portal and need a new qr code to get authenticator to work.
Virtix Health
Our team will reach out to you to help resolve
Is there a way to look up the UTN submitted by someone else?
Virtix Health
Please utilize the new Case Sharing functionality to address this and please provide us feedback at the contact us in the provider portal or call our customer service line.
1.Why can’t someone other than the submitter look up auth status? (this causes delays).
2. How can we change the provider (easily) on an already submitted request?
3.Why does AI cause denials due to no follow up pain % when it is not a repeat injection
4. How can we avoid the Virtix system from messing up our providers NPI and PTAN #’s in the future (this has happened twice and caused us a major loss in revenue?
5. Would making the dx a hard stop be possible is it doesn’t go with the requested CPT codes?
Virtix Health
- We have deployed an enhancement to allow sharing amongst team members.
- Once a case has been submitted for a particular provider, a change of provider would need to be a new case. We are currently testing a new enhancement to pull previous case information and clinical documentation forward into a resubmission. This feature will also allow you to copy information to build a new case for the Beneficiary.
- AI does not issue denials. All non affirmations are reviewed by a board certified physician.
- Virtix system leverages the information provided on previous cases for efficiency, if the information previously provided is incorrect, please reach out to us with the correct information and we will update a facility or provider’s profile.
- We appreciate this suggestion and are currently working through more logic to make submission easier and more streamlined.
When we get affirmations, we need the UTN at the same time. I read it is up to Noridian to create the UTNs, what is stopping the UTNs from being on the affirmation letters?
Virtix Health
Virtix includes the UTN in the affirmation letter once it has been issued by Noridian. To help avoid delays in care, CMS has advised WISeR Model participants to share determination outcomes even prior to UTN issuance. For your location, we observed delays in UTN generation related to how requests were being submitted, specifically, Part B prior authorization requests were submitted using a Part A PTAN for the facility. We provided this feedback to the requesting teams on multiple occasions and then connected directly with a Director from your facility to review the root cause and provide additional guidance. Since your organization updated their submission approach to align with Part A requests for the facility, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 business days to generate a UTN, so in some cases you may receive a determination before the UTN is available.
When will we be able to request a decision and receive a timely UTN number as not to delay payment?
Virtix Health
Virtix includes the UTN in the affirmation letter once it has been issued by Noridian. To help avoid delays in care, CMS has advised WISeR Model participants to share determination outcomes even prior to UTN issuance. For your location, we observed delays in UTN generation related to how requests were being submitted, specifically, Part B prior authorization requests were submitted using a Part A PTAN for the facility. We provided this feedback to the requesting teams on multiple occasions and then connected directly with a Director from your facility to review the root cause and provide additional guidance. Since your organization updated their submission approach to align with Part A requests for the facility, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 business days to generate a UTN, so in some cases you may receive a determination before the UTN is available.
1. What is expected timeline between an “Affirmed” status determination and issuance of UTN?
2. There appears to be significant delays between an “Affirmed” status and UTN issuance. If a patient is treated and the claim must be released before UTN is issued, how should providers proceed to avoid claim denials or financial liability.
3.Does an Affirmed status confirm only medical necessity/documentation requirements, or does it also verify that provider and facility enrollment requirements, including PECOS enrollment requirements, have been met?
4.During follow-up with customer service, providers receive varying explanations for pending cases, including PECOS enrollment issues or new MBI updates. How can providers effectively resolve pending cases when there is no clear or consistent explanation, and what safeguards are in place to prevent financial burden to the patient and organization.
5. With regards new MBI being generated, if the case is entered with previous (old) MBI, we have been advised a new case. Why can’t Virtix link the old and new Mbi in their system, instead of requesting that we re-start with a new case.
Virtix Health
- Virtix Health is not responsible for UTN generation, as this is handled by Noridian. Our clinical reviews are completed within three (3) calendar days of receiving a request. The MAC is responsible for UTN generation within 2 business days of receiving the request.
- The UTN generation delays for your facility were majorly due to Part B PARs using a Part A PTAN for the facility. Since submitting the correct LOB to facility PTAN, there should not be significant delays.
- When a request is received, it is first validated against HETS and PECOS. If the beneficiary, provider or facility does not pass validation, the request is dismissed. As a result, any request that receives a provisional affirmation has already successfully completed validation.
- Regarding PARs that are in a UTN Waiting or UTN Error status, Virtix Health can only identify whether an error message has been returned, and we only receive the error message provided by Noridian. At this stage of UTN generation, we do not have visibility beyond what Noridian shares. When all submitted information matches previously submitted PARs and the requester has confirmed the accuracy of the details, we are unable to determine why a UTN was not generated. To help expedite resolution, Virtix Health submits weekly spreadsheets to Noridian that include PARs in UTN Waiting and UTN Error statuses. Noridian has also advised that they are working to improve their error messaging, as the messages may not always be accurate, which can result in conflicting information provided.
- Noridian has advised us that a new PAR will have to be submitted for UTN generation to be accurate. This process is outside of our control. That said, we are actively working on a new enhancement that will allow users to create a new PAR from an existing submission, so only the necessary fields need to be updated rather than re entering all information.
What is the plan for reducing wait times? How to quickly resolve issues due to Virtix errors/systems updates?
Virtix Health
We are not currently experiencing delays in our determinations or aware of errors; please reach out with case specific issues or specific errors you are experiencing.
why don’t you back date peer to peers?
Virtix Health
We date our peer-to-peers when they occur, this is important for data accuracy and our reporting to CMS.
is it possible to create a clinic based log in to see all the patients submitted for prior auth from a given clinic versus log in per employee? When a given employee is on vacation or leaves the practice, then it is hard to track the submitted cases and response.
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
Is there a target we have to hit in order to be considered for the Gold Program?
Virtix Health
The target is an affirmation rate of 80% or higher, information about the gold carding program is available on our website.
Many providers are saying all requests are being denied until they learn what the AI bot wants. Many providers are saying the UTN number is difficult to obtain. Many providers have lots time and money waiting for procedures to be approved. How does this impact the Gold Card system?
Virtix Health
AI doesn’t deny requests; UTNs issues should be escalated with Noridian, Virtix Health is happy to help you navigate; we know this new program has been challenging, we are meeting the 3 day TAT currently and are committed to it; gold carding is based on the final outcome of the case, UTN delays are not part of that analysis.
The role of Noridian and how to contact someone at Noridian with knowledge of the wiser program.
Noridian
Noridian’s role is to process the claim based on the review decision by Virtix if it is a WISeR reviewed service. Once the review has been completed by Virtix, Noridian will issue the Unique Tracking Number (UTN) for the provider to include on the claim. Noridian’s provider contact center can be reached at 877-908-8431.
1) Why are cases being denied for “not submitting medical information” that has already clearly been submitted with the initial authorization case and is clearly noted in the patient’s chart notes by the provider? This is creating wrongful denials and shows bad faith insurance practices. This is creating all around inefficiency and duplication of work within your portal, which I’m sure many organizations statewide can attest to.
2) Why are no retro authorizations allowed for cases that have already been submitted and previously denied? Why isn’t retro authorization allowed for any case/patient?
3) Patient name search does not work. Why aren’t the names listed on the authorization dashboard list? Surely it can’t be due to HIPAA… Because we are already accessing all the PHI to create the cases….
4) Why is Peer to Peer not an option on the website, despite the denial letters stating that it is available on the website?
Virtix Health
- Please reach out to us with case examples, our determinations are made based on what is presented to us in the portal and is not in bad faith.
- It’s important for CMS’s evaluation of the program to understand how many resubmissions are occurring and why. We don’t retroactively change decisions previously rendered.
- Appreciate the feedback, we will evaluate this with our technology team. 4. It is an option on our Provider Portal website. Select prior authorization, select “resubmission”, check the P2P box.
1. Why are affirmation letters sent out without the UTN?
2. Why isn’t information on both Noridian and Virtix portals?
3. Why are requests limited to only the individual who submitted it?
4. a. How should a provider bill a service that was non-affirmed pre-service but has relevant clinical information at the time of service; should the non-affirmed UTN be used or withheld?
4. b. Would both end up being reviewed by Virtix?
5. Why are some responses provided later than the required timeframe?
Virtix Health
- CMMI directed this approach to ensure patient care proceeds without unnecessary delays while waiting for the UTN. Although we refrain from faxing letters that lack UTNs, our portal provides real-time updates. This means users can access and view the letter online, even if the UTN has not yet been assigned.
- The outcomes are delivered in the same manner as they were originally received, following the established CMMI requirement. Although we do share all outcomes with Noridian for tracking and claims purposes.
- This was initially structured to protect data and allow for user enrollment. However, from collaborated feedback from the providers and suppliers in the state of Washington, we have developed a new secure solution to allow case sharing. We anticipate this feature will be available to all providers in the coming weeks.
- If you believe there is new information available that was not provided at the time of the non-affirm, we’d recommend reaching out to our customer service team for a rereview.
- Virtix Health is within the required turnaround times.
Why UTN are not generation timely? This is delaying patient care. Thank you.
Virtix Health
Virtix includes the UTN in the affirmation letter once it has been issued by Noridian. To help avoid delays in care, CMS has advised WISeR Model participants to share determination outcomes even prior to UTN issuance. For your location, we observed delays in UTN generation related to how requests were being submitted, specifically, Part B prior authorization requests were submitted using a Part A PTAN for the facility. We provided this feedback to the requesting teams on multiple occasions and then was connected directly with a Director from your facility to review the root cause and provide additional guidance. Since your organization updated their submission approach to align with Part A requests for the facility, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 business days to generate a UTN, so in some cases you may receive a determination before the UTN is available.
If we don’t submit authorization for ESI through Virtix for the program, will this cause a denial in the claims end?
Virtix Health
Not necessarily; the case will go through a prepayment claim review performed by Virtix Health.
Currently, auth status can only be viewed in Virtix by the submitting user (i.e. provider). When will other users (i.e., facility) be able to access the auth status in Virtix?
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
I would like to learn more about how this is impacting contracted anesthesia groups that work in ASC’s.
Noridian
If the ASC procedure is denied due to medical necessity, the associated services related to that procedure will be denied if they are included on the Associated codes list, Appendix C of the CMS WISeR Physician and Supplier Operational Guide.
RE: Medicare Advantage plans We have received several dismissals for patient’s due to Virtix claims of Medicare Part C plans when it is inaccurate and verified by a Noridian portal eligibility check. How can this be resolved for future cases? We have also been receiving non-affirmed notices for “missing info” that has been clearly dictated in the already submitted provider clinical notes. How can this be resolved for future case as well?
Virtix Health
1.Virtix Health utilizes HETS to verify Medicare beneficiary eligibility; we do not use a separate internal system for this process. Given this, there should not be any discrepancies between the information reflected by Noridian and Virtix Health, as both rely HETs for beneficiary verification. We have raised this with Noridian for further review as we are not seeing any issues on our side. Once we receive additional clarification from Noridian, we will follow up with you and share the outcome.
- If you’re able to share specific examples, we’re happy to escalate those cases to our Clinical leadership team for further review. They can provide additional insight into the rationale behind the non-affirmation and will correct any errors identified. Moving forward, if you believe a PAR was inappropriately non-affirmed, please don’t hesitate to reach out to the customer service team for a re-review. The case will be escalated for a second-level review.
CPT 95861 is on the WISER list, however not a CPT code on the Virtix portal. There are several EMGs, but this is the only code on WISER. Is this a mistake? If it does require PA, do we just submit for auth via fax? I have never received a response for my faxed requests for this code. There may be codes similar to this one. Thank you
Virtix Health
CPT 95861 is an associated code on the WISeR list. It requires a primary code that is listed on Appendix A to be considered within scope of WISeR. If no code from Appendix A is relevant to the PA request, it is not in scope for the WISeR program.
There is now an option to select between Part A and Part B for LOB when putting in the Facility details. How do we know which one to choose? Is there an option to submit an inpatient request? There is no option for inpatient hospital in the drop down for place of service
Noridian
CMS did not include services performed when the patient is listed as an inpatient in the hospital. The WISeR program only applies to outpatient services billed as Type of Bill 13X, ASC, in the office or patient’s home. If performed in a hospital outpatient setting, the facility will be submitting a claim to Part A and their claim will require the UTN. The rendering provider would not need to bill their claim with a UTN. If performing in an ASC, the ASC would submit the UTN on their claim and the rendering provider would not need the UTN. When performed in the office or home setting, the rendering provider would submit medical records for review and submit the UTN on their claim that would be billed to Part B.
The biggest issue we are facing in our large multi-specialty OP hospital clinic footprint is proxy access to each of the caregivers’ cases that they have submitted. We can have several caregivers submitting for a provider. I have over 30 prior auth caregivers on my team. I need to see what has been submitted and any updates in real time. Virtix is working on this and I appreciate their collaboration.
Virtix Health
Thank you for noting our efforts! The functionality is now available.
Would like to know why CMS is denying claims when we understood this program was optional for 2026.
Virtix Health
Prior Authorization process is an option, however if a PAR is not on file you your claims will go through a prepayment review instead but WISeR oversight of these items and services is not optional.
What will the appeal process be like? Will it follow the same appeal process with the fifth and final level being a judicial review? Also, will the documentation requirements get more restrictive as time goes on. I spent 26 years in Endocrinology. I was in it when Medicare started monitoring glucose testing supplies. In the beginning the documentation was not bad but as time went on the interpretation by the auditors of what was required got more and more stringent to the point many pharmacies stopped doing more than once a day if they weren’t on insulin or more than three times a day if they were on insulin. It made it very challenging for patients who were on insulin pumps and where required to test blood sugars four times a day (at the time). Nor was it easy when you had a patient who needed to test more frequently for a short period of time for some reason like hypoglycemic episode or a change in medication dosing because they were on a steroid which was messing with their blood sugars. Documentation got to the point that the provider had to very specifically worded phrasing in the chart notes and if you did not have it worded that way word for word, the pharmacy would reject it because the auditors would reject it. Are you going to keep your documentation requirements standard, within reason, through this whole process?
Virtix Health
Your appeal process is unchanged for any claim denials; we are utilizing established NCD and LCDs for our criteria. Many of these standards have been in place for decades. We will continue to only use the established NCD/LCDs for our criteria.
what documentation is needed to get less denials
Virtix Health
For each procedure, there is an established NCD/LCD. There are hyperlinks on our website to CMS’s website. You can read what is required there or join us for office hours to discuss specific procedures and the requirements.
1. Can my colleague check the status of the case I submitted through the portal? As far as I understand, only the person who originally created the prior authorization request is able to view the status.
2. For cases that have been AFFIRMED, we noticed that it takes some time before the UTN is generated. Is there a way for the UTN to be generated immediately once the case is affirmed, and for the approval letter to include the valid date range as well?
Virtix Health
- We have new case sharing functionality, please utilize it and give us feedback.
- Noridian issues the UTN so we are unable to issue it immediately after our determination. Great feedback on the validate range to be included in the letter. We will look to update our template and obtain CMS’s approval.
We have worked through most of the kinks and have access to file on the portal now. I have been getting emails regarding claims coversheets and would like to know best practice to address those.
Virtix Health
A team member will be reaching out to you directly to assist with the prepayment process.
I am looking for tools and workflows that decrease the administrative burden of ADR fulfillment and authorizations; Online tools, prefilled forms/templates, practice management, precertification searching.
Virtix Health
Please contact us a wiser.support@virtixhealth.com we would love to partner with you to try and make this as smooth of a process as possible.
Due to the many issues with NPI’s how will you be handling the gold carding for auth ?
Virtix Health
Any cases dismissed for NPI issues will be ignored for the gold carding evaluation.
Can the portal be updated so that anyone in the same company can check on the status of pending cases that their peers have entered?
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
How do provider’s and facilities get around delays with getting UTN’s from Noridian.
Virtix Health
You could consider performing the procedure and billing the claim without the UTN (or it may become available at the time of billing); if the claim does not have a UTN, it will be routed to Virtix for a prepayment review, when requested to provide documentation, please include the affirmation letter to facilitate our claim review.
Why are only some servicing locations being reviewed for prior authorization through Wiser?
Virtix Health
CMS is piloting this program only in 6 states initially.
What are you doing with the early on erroneously denials when Virtix did not have their processes in place? This was not the hospitals errors;it was delayed based off of Virtix and their processes.
Virtix Health
Our processes were in place since the beginning of the program. The vast majority of denials and dismissals were a result of providers submitting procedures out of scope of the program or missing required documentation. Any errors related to a Virtix determination was available to be discussed via peer to peer or a resubmission. All requested peer to peers have been held with a final determination made.
how is Virtix determining gold card standard for providers? We heard that gold card standards were being reviewed immediately with no leeway to providers while all issues are resolved and addressed as there has been much confusion around the process and delay between Virtix and Noridian Medicare.
Virtix Health
Gold card information is available on our website; providers that achieve an 80% affirmation rate based on the final determination of the case will achieve gold card status.
We have numerous affirmed requests that are pending UTNs. When calling Virtix, we are told that Virtix is waiting on Noridian to supply the UTN number. When calling Noridian, they tell us to contact Viritix. Some of these cases have been pending since March with no resolution and volumes continue to rise. What is an appropriate escalation pathway to get this issue resolved?
Virtix Health
For your location, we observed delays in UTN generation related to how requests were being submitted, specifically, Part B prior authorization requests were submitted using a Part A PTAN for the facility. Since your organization updated their submission approach to align with Part A requests for the facility, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 business days to generate a UTN, so in some cases you may receive a determination before the UTN is available.
Can you explain why other Virtix users at our organization are unable to view submitted prior authorization unless they are the one that submitted the request?
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
We have had to enter in all of our providers and PTAN numbers. One was done in correctly, how do we get that voided?
Virtix Health
Please reach out to our customer support team with the correct information and we will update the provider’s profile in the system
When are auth date ranges going to be put on the approval letters?
Virtix Health
Great suggestion, we will work with CMS to update our letter template.
Identify process for prior auth, expectations, disagreement resolution, etc
Virtix Health
Hopefully the webinar answered these questions, please reach out to our customer support if you have any remaining questions.
I understand you may be an expert in the state of WA;however, do you have any insight as to see if the other WISeR qualified states are about the same output as what you have seen? Additionally, what is the best way to validate if the UTN is good for a single claim vs. series of claims for the same patient and same wound?
Virtix / Noridian
CMS is evaluating each WISeR participant, we do not have visibility on other states performance. Please contact Virtix support for your question regarding UTN for a series a claims for the same patient and same wound. Please note that skin substitute codes for wound treatment are not part of WISeR in the state of Washington and do not require a prior authorization.
would like to know what we should do when requests denied for no HEP but documentation clearly documents HEP recommendations to pt, also how these denials may impact our ability to part of the pilot coming in July for practices with 80% approval can be excluded from submitting auth requests –
Virtix Health
Any case that you feel received an incorrect determination can be escalated for a peer to peer or re-review; the final determination of the case will impact the gold carding evaluation that goes into effect in July.
why are we doing tis if voluntary?
Virtix Health
It is not voluntary; electing to submit a prior authorization is voluntary; if you decide not to, the claim will be reviewed as a prepayment claim.
Could you please clarify the effective start date of the authorization? Does it align with the date on the Provisionally Affirmed letter, or is it determined by the generation date of the UTN?
Virtix Health
You have 120 days from the letter of the affirmation to perform the procedure
I am unsure how to answer the Line of Business (LOB) question when submitting on Virtix. We will be billing for the professional charges wich are covered under Part B but services will be rendered at a hospital which get billed to Part A. This is a newer question we are being asked and even upon choosing Part B, it is being switched automatically somehow to Part A. I just don’t want to start getting claim denials. Also the Virtix site constantly updates and it’s really hard to keep up with the changes when there is no notice of upcoming updates or guidance on the changes.
Virtix Health
Noridian looks at the facilities PTAN to identify the correct LOB. If you submit a LOB Part B but use a facility Part A PTAN you will receive a UTN error. Since services are being performed at the hospital you will need to submit a Part A PAR to support the facilities PTAN. Please contact Noridian for more information. We will also be providing updates in our monthly newsletters and a banner will highlight recent changes in the portal.
why do we get cases dismiss that say detected Medicare Part C when the Noridian Portal shows member only has part A and B and D? Why do some cases that say Affirm never get Assigned a UTN?
Virtix Health
Noridian has identified a discrepancy within their portal’s beneficiary lookup tool. They recommend submitting a support ticket related to the portal and requesting a beneficiary Part C verification. Noridian also noted that they are actively working with CMS and other parties to update their systems to ensure the information reflects accurately. For your location, requesters were submitting Part B PARs while using a Part A PTAN. There was also an issue with the facility name and address. For UTNs to be successfully generated all information entered on the PAR must match Noridian’s Provider Enrollment, Name (provider/Facility), address, NPI, PTAN. Since your organization updated their submission approach to align with Part A requests for the facility and utilizing the one location, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 business days to generate a UTN, so in some cases you may receive a determination before the UTN is available.
why we are still getting 0FB UTNs for Part A Affirmed cases. Why UTNs are never assigned on Affirmed cases? Why we still can see cases on portal entered for our facility/provider like we can on Noridian.
Virtix Health
Virtix Health does not generate UTNs. For your location, requesters were submitting Part B PARs while using a Part A PTAN. There was also an issue with the facility name and address. For UTNs to be successfully generated all information entered on the PAR must match Noridian’s Provider Enrollment, Name (provider/Facility), address, NPI, PTAN. Since your organization updated their submission approach to align with Part A requests for the facility and utilizing the one location, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 business days to generate a UTN, so in some cases you may receive a determination before the UTN is available.
Is there a way for other staff follow up on prior authorizations that are submitted by other staff?
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
Live Webinar Q&A
Sending a “preliminary” affirmation without a UTN is not helpful. The fact is that if we perform the service, and have to wait 2 weeks or greater to get the number, then we are being forced to hold claims.
Virtix Health
Virtix includes the UTN in the affirmation letter once it has been issued by Noridian. To help avoid delays in care, CMS has advised WISeR Model participants to share determination outcomes even prior to UTN issuance. For your location, we observed delays in UTN generation related to how requests were being submitted, specifically, Part B prior authorization requests were submitted using a Part A PTAN for the facility. We provided this feedback to the requesting teams on multiple occasions and then connected directly with a Director from your facility to review the root cause and provide additional guidance. Since your organization updated their submission approach to align with Part A requests for the facility, we are no longer seeing the same delays or UTN-related errors. Please also note that Noridian has up to 2 busines days to generate a UTN.
Do the anticipated TATs listed here take into account SB 5395, which mandates a 3 calendar day decision for standard and 1 calendar day decision for standard and expedited electronic requests, respectively?
Virtix Health
CMS’s WISeR program requires that standard decisions are made in 3 calendar days and expedited requests are completed in 2 calendar days. Our reporting is provided in calendar days not business days.
How long has that been in effect?
Virtix Health
WISeR Program went live on January 5th 2026.
Perhaps you already answered this: What is the percentage of Affirmations that originally were a Denial/Dismissal, thus required a resubmission or peer-to-peer to overturn?
Virtix Health
It appears you are asking what % of the initial non-affirms are eventually affirmed? If so, we should be careful what conclusions to draw from that %. Is it how often Virtix was incorrect? Or is it how often the provider needed to provide additional information to get to an affirmation.
If we get a dismissal for not in scope, we could assume that means no auth is required and we can move forward with the procedure?
Virtix Health
yes that is correct assuming that there is not another prior authorization program related to that procedure. It is not needed from the WISeR program.
Is there any way to get access to some employees requests if that employee is no longer working here. I am admin so can I get access in any way?
Virtix Health
We will have customer support reach out to you. Our new functionality of case sharing likely doesn’t address gaining access to a former employee’s cases.
How do we ensure a -true- peer to peer with same-specialty physician review?
Virtix Health
Feel free to ask our physician for their specialty as the conversation begins.
When will the portal be updated so everyone under one TIN can see all submissions vs individual user driven? This is needed in order to manage cross coverage in a practice.
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
How do we get someone on the phone at Noridian that knows about billing for this program? The customer service reps don’t seem to know.
Noridian
Reach out to the Noridian Provider Contact Center.
The billing area is separate from the facilities that are initiating the UTN request; The billers are entering the data into FSS if the claim released without the UTN; In order to obtain the UTN, the billers would need to access Virtex [sic], however, the log ins are provider specific and specific to the person who initiated the request; Can access be granted to access any claims pending in the system?
Virtix Health
Please utilize the new functionality of case sharing and see if this solves the challenge you are facing. If not, please provide us feedback and we can work with you to resolve.
All my authorizations being put in a POS 11 are coming back part A is that going to mess up our claim should be part B?
Virtix Health
We have reviewed your authorizations and they look to have generated a Part B UTN. Please reach out to our Customer Service team with examples that have a Part A UTN, so th at we can further assist you.
Are their plans to optimize the portal so that multiple users can access a facility’s authorization submissions? Operationally it is very difficult when only the person who submitted the case can check status and obtain the UTN.
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
We have scenarios where Virtix made an error and did not include both CPT codes on their UTN, we have been told by Viritix this is a known issue. Their solution is to have us rekay our claims to split claims, one to pay under the UTN and one to deny and appeal. This is a large admin burden. Is there another solution for this Virtix known issue?
Virtix Health
We have reached out to you regarding your specific authorizations. As we indiciated via email, we would love to partner with you to not make this a burden on your team.
I think it is also important to know that there has been many Viritix [sic] system issues with PTANs & NPIs being loaded incorrectly.
Virtix Health
The Virtix system utilizes PTANs and NPIs that have been provided by the user entering the case. For efficiency, these PTANs and NPIs are pre-populated based on the information provided on the initial case creation when you select a particular facility or provider. If you believe the stored information is incorrect please let us know and we can update that particular facility’s or provider’s stored information.
When I submit documentation for authorization, I include the order, the note and the MRI report I’m getting non affirmed responses because “the level is not documented” However, the order indicates exactly what type of injection the doctor is ordering. How do I avoid having to call on each patient and request escalation?
Virtix Health
Our support team will reach out to you to help resolve this issue.
Is the UTN affected if the NPI was listed as an individual provider, then the claim reflects a group NPI?
Noridian
No, the rendering NPI and PTAN are needed on the prior authorization. When a claim is submitted, it will include both the rendering and the group NPI and PTAN.
What if our original claim is billed with the UTN, but Medicare still denies for CO50 & we’re told the UTN is not on the claim?
Noridian
If the UTN was entered in the fields shown on a previous slide, and denied, call the provider contact center to have the UTN checked.
Do these approvals have specific start and end dates when the procedures must be completed within?
Virtix Health
You have 120 days from an affirmation to perform the procedure.
We had a handful of patients that decided to proceed without a prior authorization, but Noridian denied the claims instead of sending to Virtix for review, thus we never received any letters.
Noridian
It seems these would have been denied in error. Please reach out to the provider contact center if these claims have not been processed correctly yet.
Does Selective Nerve Root Blocks require PA?
Virtix Health
Please review the CPT codes on Appendix A of the WISeR guide to confirm whether the CPT you are requesting authorization for is present in this Appendix.
When is the approval date range going to be on the approval letter?
Virtix Health
Great suggestion, our letter templates are approved by CMS, we will submit a request to see if we can include that information moving forward.
If we get an affirmation and the patient has to reschedule outside of the 120 days, when can we resubmit? Do we have to wait until we are outside the 120 days or can we submit before?
Virtix Health
Each affirmation is validate for 120 days. If you know the procedure will occur beyond that 120 days; we’d recommend a resubmission once you are within the 120 day window to perform the procedure. Provide notes/context in your resubmission to expedite the review process
What measures are being taken to prevent “rubber-stamping” of AI review results by physician reviewers?
Virtix Health
AI supports the review process but does not generate non-affirmation decisions or rationale. For any non-affirmed case, the reviewing physician is responsible for documenting the clinical rationale to support the determination.
Can my colleague check the status of the PA that I submitted to WISeR?
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
What is the best way to connect with NORIDIAN call center when we have difficulties with the processing of NPIs & what state they are out of ? “Facility and MAC Relationship is outside Weiser scope. Submission is dismissed as it is not required to go though the prior authorization review process under weiser ” Was sent back on multiple cases and had out facility NPI listed out of WI even though all notes confirmed in Seattle Virtix just advised contacting Noridian ?? No one could help delaying cases over 30 days just now Virtix Health is now reprocessing
Noridian
Please reach out to Noridian’s provider contact center at 877-908-8431
Had two examples just today of the Affirmed letter with UTIN says Part A Benefit, but the request was for Part B benefit, PTAN, NPI and place of service are all for Part B Benefit. Staff calls in and and it told over the phone that this is in Noridian under Part B. This has happened several times in the last few weeks and my team has to call on each one to ensure accuracy and creates extra work to ensure the affirmation is correct.
Virtix Health
We have shared this with our Product team for review. In the meantime, please note that a Part B UTN will include a “B” in the third position (e.g., 0FB). We will follow up as soon as we have additional information.
Is the date on the Provisional affirmation letter will be the start date or when a UTN number is available and an updated letter have been generated will be the start date?
Virtix Health
The date of the letter is the start date, you have 120 days from that letter to perform the procedure.
Will Virtix Health ever allow other users under the same organization TIN/NPI, to view cases that they have not submitted personally? As a larger organization with a centralized Insurance Authorization Department, being able to assist team members with approvals/status checks would be great but at this time, only the submitting team member is able to access the cases, which then creates patient care delays if team members are out unexpectedly.
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
If it is valid, would this be an appeal since it was already denied?
Noridian
If the claim denied due to no UTN and it was submitted, the Noridian call center can work to have the claim corrected.
Do ENT procedures fall under Medicare’s “select” procedures?
Virtix Health
Please see our FAQ that indicates which products and services are in the scope of WISeR. https://virtixhealth.com/wiser/FAQ/
If imaging guidance is a common denial reason, it would be more efficient to make that one of the questions asked in the initial request wouldn’t it?
Virtix Health
We align our review process with the applicable NCD/LCD guidelines with what is present in the medical record.
I think it is confusing for providers because we are thinking the surgery is an outpatient surgery in the facility setting and we attribute that to be part B vs part A; The previous slide shows that we need to list request LOB part A on the Wiser portal.
Noridian
If performed in a hospital outpatient setting, the facility will be submitting a claim and their claim will require the UTN. The rendering provider would not need to bill their claim with a UTN.
Will issues that were out of the providers control and were issues with Virtix be taken into account when reviewing for Gold Card.
Virtix Health
Under the gold card program, the final determination is what is evaluated; if a case needed to be resubmitted (missing documentation, p2p discussion, etc.) and was affirmed, none of the previous non-affirms would be included in the evaluation.
Where can we see our current approval rate?
Virtix Health
All WISeR reports require CMS approval prior to sharing; we will review with CMS this request.
If we are a single provider clinic, but bill under a group NPI, does this mean that our provider/clinic is not eligible for the gold card program?
Virtix Health
CMS guidance is that gold carding is not issued at a group NPI so you would not be eligible for the gold card program
How do claims go out for place of service 19 and 22
Noridian
If the claim is billed in a hospital outpatient setting, The rendering provider would not need to submit the UTN on the Part B claim. The facility will need the UTN on the Part A claim.
How are exempt providers reevaluated if they aren’t submitting auth requests
Virtix Health
Noridian will provide Virtix Health all paid claims during the exemption period. Virtix will then submit ADRs to the provider for up to 10 claims to perform a retrospective review
How will be notified if we qualify for the Gold Card Program?
Virtix Health
Virtix Health will issue a letter to the provider based on the contact information in our portal. We will also notify the common submitters for that provider to ensure there is awareness.
Yes, but the people that answer don’t have the knowledge to assist. Is there a specific manager we can ask for?
Noridian
You can request to have the call escalated.
When someone from the Wiser program has to create a new case due to errors, are they going to be able to share that case with us so that we can keep track of the UTN? Otherwise, our organization has no way of obtaining the UTN….
Virtix Health
Great suggestion, we will review with our internal team to see if we can assign the case to your organization after we create it.
For the portal, is there anyway we can see the patient name next to the Case ID # (on the main landing page that lists all of our cases). When we have 50 cases, with no patient name, we have to click on each one to find the right case.
Virtix Health
Great suggestion, we will review internally to see if we can make this easier to navigate.
Is that only for one case at a time?
Virtix Health
If this is in reference to case sharing, then no, you can share all of your cases at once with an individual you select. Or you can be more selective and only choose the ones you elect to share.
if we have ASC and pro claim, we cannot get the ASC on the gold program, since we use the group/ASC NPI?
Virtix Health
Gold carding is done at the provider level not the facility level; if you are using a group NPI for the provider then no you would not be eligible as per CMS guidance.
That sounds like a TON of admin burden on providers. Why cant it be TIN specific??
Virtix Health
We will review internally and determine if additional enhancements like what you are suggesting can be done while maintaining appropriate security measures. In the meantime, please leverage the case sharing enhancement that was deployed.
What was the reasoning/decision for why group NPOs would not be eligible for the exemption process?
Noridian
This is a CMS decision.
Joining late so possible this has been answered; Any future inter case visibility between users? ie, we have multiple staff that enter portal requests but they cannot easily see or f/u on each others work
Virtix Health
Please utilize the new functionality of case sharing and provide us feedback.
We have part B Affirmations and the letters come stating Part A. When we contact we are being told Wiser shows part B. Is this going to cause a denial.
Virtix Health
We have shared this with our Product team for review. In the meantime, please note that a Part B UTN will include a “B” in the third position (e.g., 0FB).
Will incorrect denials count against our affirmation rate, or will they be scrubbed from our record when an incorrect denial is overturned?
Virtix Health
The final determination will only be used, so any cases that were missing documentation and were ultimately corrected or overturned P2P’s will be treated only as an affirmation. Very important, please mark any resubmission as a resbumission and the previous case or UTN. If you resubmit and mark it as an “initial” submission, it will be treated as a new case for our gold card evaluation.
for ESI 62323 which inclued fluroscopy per CMS why is the system forcing us to add it to be affirmed?
Virtix Health
We align our review process with the applicable NCD/LCD guidelines with what is present in the medical record.
I have tried to edit cases within 5 minutes of submitting and have received an error message every time
Virtix Health
Please call our customer support to review these cases so we can investigate these specific cases.
where do we request sharing cases?
Virtix Health
You can initiate the case sharing upon logging into the portal.
the ordering doctor requests the UTN for the Hospital outpatient procedure correct?
Noridian
If the ordering doctor is requesting on behalf of the hospital outpatient. The hospital PTAN and NPI needs to be included on the Part A prior auth request.
Will we be able to receive the slides for our own reference?
Virtix Health
We will make a recording of the webinar available to you along with questions and answers that were submitted.
Why can’t we see everyone’s great questions? Its highly likely that if one person has a question, others will have the same question.
Virtix Health
We will make a recording of the webinar available to you along with questions and answers that were submitted.
Customer Service by phone.. what is the #?
Noridian
Virtix phone: 833-943-2209
Virtix Email: wiser.support@virtixhealth.com
Noridian: 877-908-8431
You can review the full “WISeR in Practice: What Washington Physicians and Providers Need to Know” webinar recording via Virtix Health On-Demand. For more information about WISeR, visit the CMS website. Additional resources include program updates, the WISeR Provider and Supplier Operational Guide, FAQs, fact sheets, and other operational materials.
