Original Medicare is adding prior authorization in 6 states (WISeR). Watch the 1:55 briefing.

COULD THIS BE COMING TO YOUR ZIP CODE SOON?

Most large gatekeeping systems roll out in phases. First comes a limited test that changes the workflow for a short list of services in a few places. Then comes operational hardening: portals, documentation rules, turnaround clocks, and vendors learning to process volume. If the model “works” on CMS’s terms, the playbook is built for expansion. WISeR sits in that first phase: CMS is testing technology-assisted prior authorization and pre-payment medical review in Original Medicare, in six states, for a pre-selected set of services. CMS itself describes WISeR as a roadmap for bringing more private-sector process innovation into CMS operations, which is why this matters beyond the initial footprint.

When you’re dealing with Medicare, the stress is not just the illness. It is the gatekeeping.

WISeR is the new gatekeeper. CMS is implementing the WISeR model on January 1, 2026. Prior authorization requests begin January 5, and the requirements apply to dates of service on or after January 15, 2026. Providers in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington who deliver WISeR “select items and services” can either submit a prior authorization request up front or provide the service and have the claim held for pre-payment medical review. Either pathway depends on meeting existing Medicare coverage criteria and submitting complete clinical documentation. If the submission is incomplete or does not match coverage requirements, it can come back non-affirmed and require resubmission, or the claim can be delayed for review.

In real life, this is the kind of change that shows up as rescheduled appointments, “still pending,” and paperwork you did not expect.

If you are on Original Medicare in one of these six states, or you help a parent or partner navigate care, this is worth knowing now, before you are under the clock.

Watch the 1:55 video:

What WISeR changes, in plain English

• It starts January 1, 2026, but the operational timeline matters: prior authorization requests begin January 5, 2026 for services delivered on or after January 15, 2026.

• Technology supports the review process, but CMS says coverage-based denials must be made by licensed clinicians, not machines.

• If prior authorization is not obtained when required, the claim can be pulled into a pre-payment review lane, which can create delays and extra documentation requests.

One quick move before you need care

If you have a test or procedure coming up in 2026 and you are in one of the six WISeR states, ask this at scheduling:

“Is this on the WISeR list for Original Medicare in my state, and who is submitting the prior authorization or documentation?”

Then ask for proof you can save: submission date and a reference number.

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Paid members get the Quick Start checklist so they can deal with WISeR plus the full downloadable Extraction Defense Kit so you are not improvising when the system stalls you.

The Extraction Defense Kit: your playbook for gatekeeping

Most people are not helpless. They are missing the playbook.

The Extraction Defense Kit is that playbook. It does not promise to “fix” every case. It gives you the language and the sequence so you can act with leverage, fast, without fighting alone.

What you get:

• The 48-Hour Quick Start
  The first moves to make today so you do not lose time when a system delays or deflects.

• The Templates Pack
  Copy-paste scripts and letters to request expedited review, correct missing documentation, get the decision in writing, and move into the appeal path fast.

• The Red Flag Glossary
  Plain-English translations of the phrases that slow people down.

• Three modules covering Healthcare, Finance, and Democracy and Accountability.

Paid subscribers also receive the Daily Intelligence Briefing, Weekly Case File, and Monthly Pattern Report.

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