Which Procedures Apply to WISeR?

Virtix Health’s role is restricted to Washington State and limited to 13 specific procedures that have been pre-determined. These procedures have been identified as high risk for fraud, waste, and abuse. The list of services include: 

• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis 
• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee 
• Induced Lesions of Nerve Tracts 
• Vagus Nerve Stimulation  
• Phrenic Nerve Stimulator 
• Electrical Nerve Stimulators  
• Incontinence Control Devices 
• Sacral Nerve Stimulation for Urinary Incontinence  
• Diagnosis and Treatment of Impotence  
• Percutaneous Vertebral Augmentation for Vertebral Compression Fracture 
• Epidural Steroid Injections for Pain Management 
• Cervical Fusion 
• Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea

For WISeR Select Items and Services, Please visit appendix A and C of the CMS WISeR Provider Supplier Guide 

How to Request WISeR Portal Access

• Send an email to: wiser.support@virtixhealth.com
• Subject Line: Requesting Portal Access

Include:

• Name
• Email
• Phone Number
• Facility Name and Address
• Facility PTAN
• Facility NPI
• Tax ID

Once processed, you will receive a welcome email with login credentials.

Why Virtix Health?

Virtix Health was chosen to be a Participant in the WISeR Model because we have been identified as a company with expertise in managing the prior authorization process using enhanced technology like artificial intelligence (AI). Our program is designed to combine cutting-edge intelligent technology with a comprehensive team of highly experienced physicians to validate determinations and conduct complex medical reviews.  

What are the goals of the WISeR Model?

The WISeR Model was developed to protect Medicare beneficiaries and taxpayers by eliminating unnecessary, low-value, or risky services and streamlining the process for speed, transparency, and interoperability. 

What is Virtix Health’s role in WISeR?

As a WISeR Participant, our job is to assess medical necessity against existing coverage criteria and affirm or non-affirm prior authorization requests and prepayment medical reviews of a select set of services or procedures, ensuring the reviews are accurate, timely and follow existing Medicare policies.   

What criteria will be used for the WISeR procedures?

The WISeR participant will use existing National and Local Coverage Determinations (NCDs and LCDs). The coverage criteria are available in the WISeR Model Provider and Supplier Operational Guide.  

Does artificial intelligence replace doctors in the WISeR program?

No, artificial intelligence can only affirm a request. All non-affirmations will be reviewed and decided on by a board-certified medical doctor with a license to practice in at least one U.S. state and relevant clinical expertise, ensuring that human medical judgement remains central to every decision. 

Who qualifies as WISeR providers and suppliers?

Original Medicare-enrolled providers and suppliers in WISeR participants’ jurisdictions who furnish WISeR select items and services to Original Medicare beneficiaries will be referred to as WISeR providers and WISeR suppliers. 

What are the pathways for coverage review under WISeR?

WISeR providers and suppliers will have two options under WISeR to receive coverage determinations, including prior authorization and pre-payment medical review.  

How can providers and suppliers submit a prior authorization?

Submit a prior authorization request to receive a determination prior to administering WISeR select items and services. It may be submitted via an electronic portal, mail, or fax. WISeR providers and suppliers are encouraged to use the electronic portal. A determination will be issued within 3 days of receiving the request.  

How can providers and suppliers submit a pre-payment medical review?

After furnishing the WISeR select items and services and submitting the claim, the MAC will request that the WISeR participant complete the review of the WISeR procedure. An ADR (additional documentation request) will be sent to the WISeR provider or supplier who submitted the claim. The WISeR provider/supplier that submitted the claim will have 45 days to return the information for consideration. A determination will be issued within 3 days of receiving all necessary documentation. 

What happens if a WISeR prior authorization request is non-affirmed?

The WISeR provider or supplier may resubmit the prior authorization request and provide additional information to support the resubmission and/or they may request a peer-peer conversation. 

What happens if a WISeR pre-payment claim review is non-affirmed?

In cases where the pre-payment medical review results in a claim non-affirmation, the provider or supplier can appeal the denial utilizing the existing Medicare appeals process. 

What if I need a response faster than three days?

A WISeR Provider/Supplier may submit a prior authorization request for expedited review if delays could seriously jeopardize the WISeR beneficiary’s life, health, or ability to regain maximum function. If the WISeR participant confirms this risk via supporting documentation from the WISeR Provider/Supplier, then prior authorization request will be completed within 2 days of receipt of the expedited request. 

What WISeR program resources are currently available?

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.