Medicare beneficiaries in six states now face a new requirement before receiving certain medical services: prior authorization from the federal government. The Centers for Medicare and Medicaid Innovation launched the Wasteful and Inappropriate Service Reduction model, known as WISeR, covering Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The program runs from January 1, 2026, through December 31, 2031, and it represents the first time Traditional Medicare has applied prior authorization at this scale to its fee-for-service population.
How WISeR changes the claims process for six states
Under the WISeR model, providers treating Traditional Medicare patients in the six designated states must obtain approval before delivering certain services or face a pre-payment medical review of their claims. That distinction matters: a provider who skips the prior authorization step does not simply receive payment as usual. Instead, the claim triggers a review before any reimbursement is issued, which can delay payment and increase administrative burden on clinics and hospitals already stretched thin.
Prior authorization has long been standard in Medicare Advantage and commercial insurance, but Traditional Medicare has historically avoided it for most services. The Congressional Research Service noted that this limited use made the WISeR rollout a significant departure from how the program has operated for decades. For the roughly 34 million Americans enrolled in fee-for-service Medicare, the pilot signals that CMS is willing to test managed-care-style tools in the traditional program.
The practical question is whether this shift will produce a visible difference in how care is delivered. If WISeR works as designed, claims volume for targeted services in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington should diverge from patterns in non-pilot states within the first 18 months. CMS publishes claims data regularly, and researchers will be able to compare utilization trends across state lines once enough quarters of data accumulate. A measurable drop in the pilot states, without a corresponding decline elsewhere, would be the clearest early evidence that prior authorization is changing provider behavior in Traditional Medicare.
CMS transmittals and the operational framework behind WISeR
CMS formalized the program’s mechanics through Transmittal R13570DEMO, which established the prior authorization and medical review process and created a quarterly Change Request cycle for updating the list of covered services. That quarterly cadence means the specific procedures requiring approval can expand or contract every three months, giving CMS flexibility to adjust the model as data comes in but also creating uncertainty for providers who must track shifting requirements.
The WISeR model page identifies performance years running from 2026 through 2031 and names the six participating states. CMS’s FAQ directs providers to a separate Operational Guide for the full list of CPT and HCPCS codes subject to prior authorization, but that guide has not been included in publicly summarized materials reviewed for this article. Without the complete code list, it is difficult to assess exactly which procedures are affected or how broadly the requirement reaches into everyday clinical practice.
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David M. Keller is a finance writer based in Columbus, Ohio, covering personal finance and consumer-focused economic topics. He earned his degree in journalism from Ohio University and began his career reporting on local business and economic trends for a regional media outlet. Since then, he has contributed to a variety of online publications, focusing on clear, practical coverage of topics such as cost of living, debt, and everyday financial decision-making.
