skills/medicare-notice-triage/references/wiser-scope.md

# WISeR scope reference

Use the current CMS WISeR model page and the operational guide posted there. The guide is revised during the model; never rely on a stored version number or a memorized deadline.

## Scope check

Confirm all of the following from the current guide and claim:

- state and relevant model participant/MAC;
- service date within the model period;
- provider/supplier and beneficiary applicability;
- primary code versus associated code;
- diagnosis pointer and actual anatomical site where relevant;
- prior authorization versus prepayment review path; and
- the notice's requested disposition and response instructions.

A code appearing somewhere in the guide does not by itself establish that every claim line or diagnosis is in scope.

## Out-of-scope concern

Use this posture:

> Respond on time, preserve the claim, identify the scope mismatch precisely, and request the disposition supported by the current guide and notice.

Do not advise ignoring the request. Attach a concise claim-line map showing code, diagnosis pointer, anatomical site if relevant, service date, and the guide provision relied on.

## Sources

- CMS WISeR model page: https://www.cms.gov/priorities/innovation/innovation-models/wiser
- CMS WISeR FAQ: https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions
- Arclight WISeR scope analysis: https://www.arclightaction.com/insights/wiser-adr-outside-model-scope