Which Procedures Apply to WISeR?

Virtix Health’s role is restricted to Washington State and limited to 12 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: 

• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
• Induced Lesions of Nerve Tracts (NCD 160.1)
• Vagus Nerve Stimulation (NCD 160.18)
• Phrenic Nerve Stimulator (NCD 160.19)
• Electrical Nerve Stimulators (CPT 63655) (NCD 160.7)
• Incontinence Control Devices (NCD 230.10)
• Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
• Diagnosis and Treatment of Impotence (NCD 230.4)
• Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (LCD L34228)
• Epidural Steroid Injections for Pain Management (LCD L39240)
• Cervical Fusion (CPT 22554) (LCD L39758)
• Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (LCD L38310)

For WISeR select items and services, along with the select CPT codes, please visit appendix A and B of the CMS WISeR Provider Supplier Guide.  

How Can I Access the Virtix Health WISeR Provider Portal?

Washington providers and suppliers may login or request access to the Virtix Health WISeR Provider Portal by visiting wiser.portal.virtixhealth.com.

Registration is available through both the provider portal and email; however, using the portal is the preferred and fastest method to receive your login credentials.

If you already have Virtix Health WISeR Provider Portal access and are unable to login, this may be due to an expired password, MFA issue, or account lock. Please refer to the Virtix Health Provider Portal User Guide for troubleshooting or contact the support team directly for additional support.  

How to Request WISeR Portal Access

To get started, visit wiser.portal.virtixhealth.com and select Register Now. Registering directly on the provider portal is the preferred and fastest way to receive your login credentials. You will be prompted to provide user information, facility details, and provider information. Once your registration is processed, you will receive a welcome email with your login credentials.

Alternatively, you may request portal access by emailing wiser.support@virtixhealth.com with the subject line “Requesting Portal Access.” Please include your name, email, phone number, facility name and address, facility PTAN, facility NPI, and tax ID. After processing your request, you will receive a welcome email with your 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 aims to:

• Focus health care spending on items and services that will improve patient well-being;
• Apply commercial payer processes that may be faster, easier and more accurate;
• Increase transparency on existing Medicare coverage policy; and
• De-incentivize and reduce use of medically unnecessary care.

 

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. A human clinician with relevant clinical expertise for selected items and services must review every non-affirmation. To be provisionally affirmed, the request for prior authorization must meet all applicable Medicare rules and policies including those defined in the clinical documentation requirements as set forth in the WISeR Provider and Supplier Operational Guide (PDF).

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. Washington's Medicare Administrative Contractor (MAC) for WISeR is Noridian. According to the CMS release dated April 7th, any provider or supplier contracted with a MAC other than Noridian is considered out of scope for the Virtix Health WISeR program.

 

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?

Providers and suppliers can submit a prior authorization request directly to the Virtix Health portal which will have a 72 hour turnaround time. For prior authorization requests sent to a MAC rather than through a WISeR participant electronic portal, additional time may be needed for the MAC to process and forward the information to the participant, and then to forward the decision back to the provider/supplier.

Alternatively, providers and suppliers may choose not to submit a prior authorization request. If a provider or supplier chooses not to submit a prior authorization request for an included service, their claim for the service would be subject to pre-payment medical review for any date of service on or after January 15, 2026.

 

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 denied?

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. 

When resubmitting, providers should select "Resubmission" for Request Type. All resubmissions should include the UTN issued for previous case. If it is not available, select the box "Waiting for UTN," you will then be asked to include the previous submission case ID.

 

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

In cases where the pre-payment medical review results in a claim denied, 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.

Is a diagnosis code always required?

No, some CPT codes do not require a diagnosis code. For WISeR select items and services, along with the select CPT codes, please visit appendix A and C of the CMS WISeR Provider Supplier Guide.

 

Can I submit a prior authorization request with a past procedure date?

No, to be eligible for prior authorization within the WISeR program, the anticipated procedure date must be in the future and include one of the 12 specific procedures that have been pre-determined.

 

What happens if my prior authorization request is missing information or documentation?

All prior authorization requests must include complete documentation, such as recent and relevant clinical notes, as well as imaging and lab reports that support medical necessity. Missing information or documentation may result in a dismissal or delay. Please refer to the Virtix Health Provider Portal User Guide on tips for success in WISeR and best practices for submissions.

 

When can a peer-to-peer (P2P) be requested, and how do I schedule one?

When resubmitting a request, you will have the opportunity to request peer-to-peer clinical review to inform the new determination. A clinician with specialty expertise on the condition under review will connect with the WISeR provider or supplier during peer-to-peer review. You may submit a peer-to-peer request through the Virtix Health WISeR Provider Portal or contact the support team directly. Once a UTN is assigned and a non‑affirmed decision is issued, include the case number, UTN, or other case‑specific details in your request.

 

What is a UTN and why am I still waiting for it, or when will I receive it?

Our team works directly with Noridian to streamline the process of obtaining a Unique Tracking Number (UTN) for all clinical determinations. The designated UTN is assigned by Noridian after your eligibility has been confirmed and your clinical review is complete, at which point the UTN is requested on your behalf. While you are waiting, you can download your determination letter, and once the UTN becomes available, the letter will be updated to include the UTN for your reference.

 

How does Part C enrollment affect eligibility?

Members enrolled in Medicare Part C are not eligible for the WISeR program. If you have questions or concerns regarding eligibility, please reach out to our support team.

 

Why does my case show a delay?

Delays may occur due to missing documentation, UTN assignment, or processing timelines. Please refer to the Virtix Health Provider Portal User Guide for documentation requirements, as well as tips for success in WISeR and best practices for submissions.

 

How will I receive determination letters?

Letters are available on the Virtix Health WISeR Provider Portal and may also be mailed or faxed, depending on the submission method used to request prior authorization.

 

Why are my submissions being non-affirmed?

Some National and Local Coverage Determinations (NCDs and LCDs) require documentation proving that necessary workups were completed or treatments attempted before performing one of the 12 specific procedures in the WISeR program. Submitting documentation through recent office visit notes and order sheets help meet LCD and NCD requirements for prior treatments and workups. Please avoid placing notes in the comment box of the Virtix Health WISeR Provider Portal, if possible. Additional information and the coverage criteria are available in the WISeR Model Provider and Supplier Operational Guide.

 

How can I track and manage my WISeR cases?

To monitor your WISeR cases, log into the Virtix Health WISeR Provider Portal and select View Cases from the main menu. This will display all cases linked to your account and assigned facilities, along with their current status and determination. Common statuses include Submitted (Case has been received), In Review (Case is under clinical review), Completed-PendingUTN (Review is complete, pending UTN assignment from the MAC), ADR Response Pending (Documentation is required for Pre-Payment Claim Review), and Completed (Review is complete). Determinations such as Pending (Case has been received and being validated), Dismissed (Case did not meet eligibility criteria for the WISeR Model Program), Non-Affirmed (Request did not meet coverage criteria), or Affirmed (Request meets coverage criteria) indicate the outcome or next steps for each case. Refer to the status and determination descriptions on the portal for more details about each stage of the review process.

 

Who can I contact if I have a question about a specific prior authorization request?

Questions about a specific prior authorization request should be directed to Virtix Health, using the following contact information:

• Portal: wiser.portal.virtixhealth.com
• Email: wiser.support@virtixhealth.com
• Phone: 833-943-2209
  • Our team will contact you within 24 hours of receiving your request, whether it's by phone or email.

The CMS WISeR Model Help Desk (WISeR@cms.hhs.gov) provides support with program-specific, operational, or implementation questions related to the WISeR model. The CMS WISeR Model Help Desk is unable to verify or provide information about specific prior authorization requests that are submitted to a WISeR Model Participant or MAC and will refer such inquiries to the participant.

 

What WISeR program resources are currently available?

For more information about WISeR, visit the CMS website. Additional resources include program updates, the WISeR Model Fact Sheet; WISeR Provider Fact Sheet; The Federal Registrar Notice; and WISeR Model FAQs.

Ask a question about the Virtix Health WISeR Provider Portal.