Review pathways
Prior authorization vs pre-payment review
The central difference is when review occurs. That timing changes scheduling, evidence, claim, and follow-up operations.
CMS and assigned official participant instructions control route selection and procedure. WISeRly is independent, not CMS-affiliated or endorsed, not an official participant, does not issue determinations, and does not guarantee authorization or payment.
Side-by-side operational view
| Question | Prior authorization | Pre-payment medical review |
|---|---|---|
| When? | Before the service is furnished. | After the service and claim submission, before payment. |
| Primary operational focus | Scope, complete request, scheduling, decision status, and any resubmission before service. | Claim linkage, timely response to the official documentation request, and payment-status follow-up. |
| Key risk | Proceeding without the required favorable official status. | Payment delay or unfavorable claim review after the service has occurred. |
| What controls? | Current CMS requirements and the assigned participant's exact instructions and notices. | |
Terminology, availability, election, transition, and resubmission details can change. Verify them for the specific service and date.
Do not collapse distinct outcomes
A preparation “ready” label is not an affirmation. An affirmation is not a payment guarantee. A claim remains subject to other applicable Medicare requirements. Preserve exact official wording and route uncertain notices to qualified staff.
Enhanced technology or AI-assisted review may support an official workflow, but does not erase the distinction between automated assistance and a human clinical determination. WISeRly performs neither official function.
Plan timelines · Interpret outcomes carefully · Prepare participant handoff
Read the current official instructions
CMS WISeR model page
CMS Provider and Supplier Guide v7.0, updated July 24, 2026
Use synthetic information only in public WISeRly demos. Do not enter patient identifiers, clinical records, claims, or PHI.