Written by Jessica Miller · Published November 12, 2026 · Last reviewed November 12, 2026
No. A WISeR provisional affirmation is a preliminary finding that a future Original Medicare claim likely meets coverage, coding and payment rules. The claim still needs the unique tracking number (UTN) and the affirmed codes, and CMS says affirmed claims can still be denied.
| Figure | Number | What it means for your revenue cycle |
|---|---|---|
| Humata provisional affirmation notice, Oklahoma | Within 3 minutes, versus up to 24 hours for CMS processing | Scheduling can start sooner. The claim still waits on the UTN and normal claim edits |
| Humata eligible requests provisionally affirmed, last 30 days | Over 65% of more than 2,980 cases | Company figure. The rest went to human review for missing documentation or NCD or LCD criteria |
| Humata human-review turnaround | 2 hours, 15 minutes on average | Applies to cases its system could not affirm in minutes |
| Provisional affirmation validity | 120 days from the decision | A service delivered after day 120 needs a new request |
| WISeR footprint | Six states, January 1, 2026 to December 31, 2031 | Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, Original Medicare only |
| Highmark prior authorization list | 81 codes removed, effective November 1, 2026 | Fewer auth requests at Highmark. Coding edits on those claims stay the same |
Sources: Humata Health release via Business Wire , CMS WISeR Provider and Supplier Operational Guide , CMS WISeR model page , Highmark provider notice .
What is a WISeR provisional affirmation?
The Wasteful and Inappropriate Service Reduction (WISeR) Model is a CMS Innovation Center test in which technology companies review prior authorization requests for selected Original Medicare services. A provisional affirmation is the "yes" decision. CMS defines it in its operational guide as "a preliminary finding that a future claim submitted to Medicare for the WISeR Select Item or Service likely meets Medicare's coverage criteria, including coding and payment rules." It stays valid for 120 days.
The word that matters is "likely." A provisional affirmation is not a payment decision. Your MAC still adjudicates the claim.
WISeR covers office (POS 11), home (POS 12), ASC (POS 24) and hospital outpatient (TOB 13X) settings. The CMS model page lists skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis among the selected services. Medicare Advantage is out of scope.
Why a fast yes can still end in a denied claim
Picture the usual handoff. The auth desk gets the affirmation, the case goes on the schedule, and nobody tells coding which codes were affirmed.
CMS is direct about this in the guide. A claim with a provisional affirmation on file "will likely be paid" only "if all Medicare coverage, coding, and payment requirements are met." CMS adds that such a claim may still be denied for "technical requirements that can only be evaluated after the claim has been submitted for formal processing," or for new information that would have changed the decision.
Under the guide's section on associated services, claims for anesthesiology, implanted devices, physician services and facility services tied to the WISeR service "will not be paid" if the primary service is non-affirmed or denied in claims processing. One coding mismatch on the primary service can pull the anesthesia and facility claims down with it.
What changed on November 10, 2026?
Humata Health, Oklahoma WISeR. Humata, the WISeR participant for Oklahoma, said in a Business Wire release that providers can now learn of a provisional affirmation "within three minutes." Before, Humata waited for CMS's own system to process the request, which "could take up to 24 hours." Humata says it provisionally affirmed over 65% of eligible WISeR requests across more than 2,980 cases in the last 30 days. Humata says its system "can only say 'yes' to a case and cannot issue a denial" and routes the rest to a licensed clinician, with average provisional turnaround of 2 hours, 15 minutes. The release says outright: "A provisional affirmation covers clinical criteria only, so other payment and coding rules still apply before a claim is processed for payment."
Humana, Evolent and American Oncology Network. In a joint release , the three said AON practices that "demonstrate adherence to established quality and evidence-based treatment standards will no longer need to submit traditional prior authorization requests" for most anticancer drug therapies. The model launched across eight states, which the release does not name. This is a Humana program, separate from WISeR.
Highmark. Highmark removed 81 codes from its prior authorization list, effective November 1, 2026. Of those, 68 are add-on codes.
None of the three changes how the claim gets coded.
What do the released CMS letters say about WISeR oversight?
On October 27, the Electronic Frontier Foundation published records it obtained from CMS through its public-records lawsuit. EFF says CMS sent requests for information or corrective action plans to at least four of the six WISeR vendors in the program's first three months. In a letter to Virtix, CMS cited "denials that appear inaccurate or inconsistent with applicable criteria." EFF's post does not name Humata.
In a May 12, 2026 GAO decision on the model, GAO noted that participant payments are "calculated from requests that did not result in a paid claim," unlike MACs, which are paid on the cost of reviewing claims. CMS requires licensed clinicians to make every non-payment recommendation.
Provisional affirmation vs. claim payment
A provisional affirmation answers a coverage question before the service. Based on the documentation you sent, it predicts that a claim for the codes you requested will likely meet coverage, coding and payment rules.
Claim payment answers a billing question after the service. Your MAC checks that the claim carries the UTN, bills the codes that were affirmed, and passes Medicare's coding and payment edits.
Humata's notice and the CMS tracking number are also two separate things. Humata can tell you "yes" in minutes. CMS still "will continue to process each prior authorization request and issue a unique tracking number on its own timeline," and the guide says the UTN must be included "on each submitted claim if the service is rendered." A fast yes without the UTN on the claim is an incomplete claim.
How do you keep an affirmed WISeR case from denying at the claim?
- Store the affirmed codes with the case. Record the exact CPT or HCPCS codes, the UTN and the decision date. Coders should see them before final coding.
- Compare the operative note to the request. If the surgeon did more or something different, the claim no longer matches the affirmation. Under CMS's partial affirmation rule, effective April 1, 2026, one service on a request can be affirmed while another is not.
- Check units, modifiers and place of service. Extra units, a missing laterality modifier, or a POS that does not match the affirmed setting will surface at the claim. Our guide to bilateral modifier coding covers the laterality cases.
- Confirm the diagnosis codes support the NCD or LCD. The request carried diagnosis codes pertinent to the service. The claim needs the same support. Our LCD vs NCD coverage check walks through the lookup.
- Put the UTN in the right field. On an electronic 837 professional claim, CMS places it in loop 2300, REF segment, with qualifier G1. Institutional claims use the Treatment Authorization field. In ASCs and outpatient departments, WISeR selects facility claims, so the facility claim carries the UTN.
- Watch the 120-day clock. Services delivered after 120 days need a new request.
- Put exempt providers in the right NPI field. CMS grants exemption by individual NPI. The exempt NPI goes in the rendering field for office and home, the referring or ordering field for ASCs, and the operating provider field for outpatient departments.
If you skip prior authorization, the MAC suspends the claim for pre-payment review. You get 45 days to answer the documentation request, or the claim is denied.
Worked example: a skin substitute with a partial affirmation
A wound care clinic in Texas or Oklahoma requests prior authorization for CPT 15271, the first 25 sq cm of a skin substitute graft, and add-on CPT 15272. The WISeR participant affirms 15271 and non-affirms 15272 because the wound measurements in the request do not support the added area.
The procedure goes ahead. If the claim bills 15271 and 15272 together, 15272 has no affirmation behind it. The coder needs the decision letter, the wound measurements from the procedure note, and the UTN before releasing the claim. The clinic can resubmit 15272 with better documentation. The guide notes that skin substitutes are currently not subject to WISeR prior authorization in MAC jurisdiction JF, which covers Arizona and Washington.
The same applies to Humana's AON oncology model. Dropping prior authorization does not change drug units or JW and JZ waste reporting .
Where MediCodio AI fits
MediCodio AI does not submit prior authorization requests or predict affirmations. It works on the coding that the claim depends on after the clinical yes.
CODIO AI applies AI medical coding to procedural and outpatient charts. Complete charts flow through AutoPilot for fully autonomous coding. Charts where the documentation is thin or contradictory stay in CoPilot, where certified coders review and finalize the output.
Every code ships with its documentation passage and the compliance rule behind it, a 100% code-level audit trail . If a MAC questions a WISeR claim, your team can see which passage supported each code, unit and modifier. No coding tool can promise a claim will be paid. See how this works for ASC coding and RCM companies .
What has not changed
CMS states it in one line: "WISeR does not change Medicare coverage or payment policy." NCDs, LCDs, CPT and HCPCS guidelines, and Medicare payment edits apply to an affirmed WISeR claim the same way they apply to any other claim. Our guide to coding denials and CARC codes covers the denial reasons you will still see.
Frequently asked questions
Is a WISeR provisional affirmation a promise of payment?
No. CMS calls it a preliminary finding that a future claim likely meets Medicare coverage, coding and payment rules. The claim can still be denied for technical requirements checked during processing or for new information. It must carry the UTN, the affirmed codes, and documentation that meets the NCD or LCD before your MAC will pay it.
Can Humata's AI deny a WISeR prior authorization request?
Humata says its system can only affirm a case and cannot issue a denial. Cases it cannot clear go to a licensed clinician. CMS rules also require human clinician review before any WISeR non-affirmation. Humata reports average provisional turnaround of 2 hours, 15 minutes for those reviewed cases.
Which states and settings does WISeR cover?
WISeR runs from January 1, 2026 to December 31, 2031 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It applies to Original Medicare only. Covered settings are office, home, ASC and hospital outpatient departments. Inpatient-only services, emergency services, and services that would put patients at risk if delayed are excluded.
Where does the UTN go on a WISeR claim?
The MAC generates the unique tracking number. On an electronic 837 professional claim, report it in loop 2300 in the REF segment with qualifier G1. Institutional claims carry it in the Treatment Authorization field. CMS says the UTN belongs on the claim whether the decision was an affirmation or a non-affirmation.
Is the Humana and AON oncology model part of WISeR?
No. WISeR is a CMS model for Original Medicare in six states. The Humana, Evolent and American Oncology Network model is a Humana program announced November 10, 2026. Qualifying AON practices no longer submit traditional prior authorization for most anticancer drug therapies, across eight states the release does not name.
Book a Demo to run an accuracy review on your own charts, including recent WISeR procedures, and see the documentation passage behind every code, unit and modifier.
Sources
- Humata Health release, November 10, 2026
- Humana, Evolent and AON release, November 10, 2026
- CMS, WISeR Model page
- CMS, WISeR Provider and Supplier Operational Guide, version 7.0, July 24, 2026
- GAO, B-337994, May 12, 2026
- EFF WISeR records post, October 27, 2026
- Highmark prior authorization notice, November 10, 2026