myCGS

Forms

Prior Authorization: WISeR

Ohio Part A & Part B users can access this form. Use the PA WISeR form to request prior authorization for items or services subject to the Wasteful and Inappropriate Service Reduction (WISeR) Model.

Forms

  1. Select ‘Forms’.
  2. Select ‘Prior Authorization’ from the ‘Select a Topic’ drop-down menu.
  3. Select ‘PA WISeR’ from the ‘Select a Type’ drop-down menu.
  4. Click the link to open the form.

PoS

Facility or Group Practice Information

This section describes the place of service (i.e., where you plan to provide the WISeR items or services). Report the following:

  • Facility Name
  • PTAN
  • NPI
  • Fax Number (optional; report the place of service fax number only)

Request Details

Select the appropriate ‘Place of Service’ option:

  • Part A users: Hospital Outpatient Department (only option)
  • Part B users:
    • Ambulatory Surgical Center
    • Physician Office
    • Home Setting

Select the appropriate request type:

  • Initial Request (first request for this beneficiary and date of service)
  • Resubmission Request (subsequent request after receiving a non-affirmation decision)

Info

Requestor Information

This section describes the person who should receive the prior authorization decision. Report the following:

  • First Name
  • Last Name
  • Email
  • Phone Number
  • Extension (if applicable)
  • Send decision by fax (check box, if applicable)

Beneficiary Information

This section describes the patient who will receive the items or services. Report the following (as it appears on the current Medicare card):

  • Medicare ID
  • First Name
  • Last Name
  • Date of Birth

You may use the ‘Validate Beneficiary’ button to verify that the information you enter matches the eligibility file.

Phys Info

Attending/Rendering Physician Information

This section describes the physician who will provide the item or service. Report the following:

  • First Name
  • Last Name
  • NPI
  • Fax Number (optional; the prior authorization decision will be faxed to this number)
  • Address (optional; the prior authorization decision will be mailed to this address)

Services Requested

This section describes the WISeR items or services for which you’re requesting prior authorization. Report the following:

  • CPT/HCPCS Codes
    • Key 1 CPT/HCPCS code; click ‘Add’.
    • You may add up to 4 codes.
  • Primary Diagnosis Code
  • Date of Service

Attachments

Attachments

You must attach at least 1 PDF document (up to 40 MB). The total size for all attachments can’t exceed 150 MB.

Select ‘Choose File’. Follow the prompts to locate and attach your document(s).

Submit

When ready, click ‘Submit’.

The e-Signature box will display. First, review to ensure all required fields and attachment(s) are complete and correct.

  • If satisfied, select ‘Ok’.
  • If not, select ‘Cancel’ to make any corrections to the form or attachment(s).

Messages

Go to ‘Messages’ to view the following notifications in your Message Inbox:

  • After you submit the form, myCGS will deliver a message with your request details (confirmation).
  • Once Innovaccer completes the review, you’ll receive a decision letter.

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