1. Geography
Apply the official location rule to the place where the service is furnished; do not substitute headquarters, billing office, or beneficiary address unless instructed.
Scope control
Does CMS WISeR apply?
Treat applicability as a multi-factor, date-sensitive check—not a conclusion based on state or service name alone.
CMS and current assigned official participant instructions are authoritative. WISeRly is independent, not affiliated with or endorsed by CMS, not an official WISeR participant, does not issue determinations, and does not guarantee authorization or payment.
Six factors to verify
2. Beneficiary and program
Confirm the beneficiary’s applicable Medicare coverage arrangement and any program-specific scope rule.
3. Selected service
Match the exact service and code to the list effective for the anticipated date.
4. Setting and supplier facts
Verify place of service, provider/supplier type, ordering/referring facts, and other official qualifiers.
5. Timing
Check model and service effective dates. A prior case or old job aid does not prove current scope.
6. Exclusions or exemptions
Document the official basis. Never infer exempt status from past handling.
Record the applicability decision
Capture each input, source URL, source version/effective date, retrieval date, conclusion, uncertainty, and reviewer. If facts are incomplete or sources conflict, mark the result “needs official clarification,” not “out of scope.”
AI-assisted or enhanced-technology review is separate from human clinical determinations. An automated scope check can identify questions; it cannot make an official applicability or clinical decision.
Next: confirm the selected service · Review exemptions · Escalate through official handoff
Official sources
Synthetic/no-PHI boundary: test applicability only with fictional or de-identified demonstration facts in public WISeRly experiences. Do not enter PHI.