CMS WISeR Model - NJ

If you need any assistance please email wiserhelpdesk@genzeon.com or visit our portal page at https://portal.hip.one/.

WISeR is a voluntary model for vendors/MAC operations, but prior authorization is required for included services furnished in pilot states.

Providers submit prior authorization requests to Genzeon or Novitas. The prior authorization request can be submitted via Genzeon’s portal, Novitasphere, by fax at (484) 200-2155, or by mail to Genzeon Corporation, 256 Eagleview Blvd, Suite 509, Exton, PA 19341. The coversheets can be accessed via Genzeon’s or Novitas’ websites.

When submitting prior authorization through the portals, the information will automatically transfer to the coversheet.

Prior authorization requests submitted directly to Genzeon are sent using Genzeon’s designated cover sheet and faxed to (484) 200-2155 or mailed to Genzeon Corporation, 256 Eagleview Blvd, Suite 509, Exton, PA 19341.

Prior authorization requests submitted to Novitas using the Novitas WISeR model coversheet, whether by fax, mail, or Novitasphere, will be forwarded to Genzeon.

A WISeR model prior authorization request requires specific elements to be present on the submission. To avoid potential dismissals due to an incomplete prior authorization request, submitters are highly encouraged to use the Genzeon or Novitas coversheet.

Providers can refer to the Wasteful and Inappropriate Service Reduction (WISeR) Model Provider and Supplier Operational Guide, Section 3.2: General Prior Authorization Request Documentation.

Yes, a third party can submit a prior authorization request on behalf of the provider or facility, provided the third party has access to the necessary information to submit a complete request.

CMS allows a physician or practitioner to submit a prior authorization request on behalf of a facility. Physicians and practitioners who submit the prior authorization request on behalf of a facility should include their contact information on the prior authorization request cover sheet, in addition to the facility’s contact information. If the physician or practitioner is not the requester and would like to obtain a copy of the decision notification, they should contact the facility.

All procedure codes within the same category that require prior authorization for the same beneficiary must be filed on a single claim and listed on the coversheet for review. The categories and codes are available in Appendix A of the Wasteful and Inappropriate Service Reduction (WISeR) Model Provider and Supplier Operational Guide.

Yes, the prior authorization request must list the number of units that are needed for the specific CPT code. Units are determined based on the HCPCS or CPT code descriptor for the service. Refer to Appendix A of the Wasteful and Inappropriate Service Reduction (WISeR) Model Provider and Supplier Operational Guide for specific code descriptors.

Once the procedure has started and needs to be changed to a different CPT code, you would verify that the new CPT code requires prior authorization, as outlined in Appendix A of the Wasteful and Inappropriate Service Reduction (WISeR) Model Provider and Supplier Operational Guide.

· Due to the timing of this discovery, prior authorization cannot be requested before the procedure. If the CPT code requires prior authorization, the claim will be filed with no UTN and will be stopped for prepayment review. An ADR letter will be sent requesting documentation for the service performed. When responding with documentation, please include the documentation sent for the original affirmed prior authorization request, the affirmed decision letter, and the documentation supporting the medically reasonable and necessary reason for switching the service CPT codes during the procedure.

· If the CPT code does not require prior authorization, the claim will be filed without the UTN and will process as usual.

A full list of FAQs can be found on the WISeR portal page, under Blogs: https://portal.hip.one/blog/faq-wiser-model.