Buried inside the WISeR pilot (the CMS Wasteful and Inappropriate Service Reduction Model that launched January 1, 2026) is a specific mechanic that most practices in the six pilot states have not yet operationalized. Practices that hit a 90% affirmation rate on covered services earn exemption from Medicare prior authorization entirely, at least within the WISeR-covered service categories.
The exemption is not a small carrot. It is complete relief from PA workflow, staffing burden, and denial risk on the affected services. For practices with meaningful traditional Medicare volume in the six pilot states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington), earning the gold card is worth designing operations around.
Here is what 90% affirmation actually requires, and how to build for it.
What the Affirmation Rate Actually Measures
The affirmation rate is not a subjective measurement. It is a specific ratio calculated across your PA submissions within the WISeR covered service categories.
Affirmation rate = the percentage of your prior authorization requests that receive an affirmative (approval) response on first submission, without needing amendment, additional documentation, or appeal.
To hit 90%, nine out of every ten PA requests your practice submits must clear on first pass. Not eventually. Not after amendment. On first submission. That is a high bar, and it is intentional. CMS designed the threshold to reward practices whose PA submissions are already so clean that continued PA oversight adds no value.
Why This Is a Claim Quality Stat, Not a Volume Stat
The important structural insight about the WISeR gold card is that affirmation rate is earned before the PA request goes out, not after. There is no way to backfill it through appeals or aggressive follow-up. It is a measurement of upstream claim quality: how well your practice documents medical necessity, how accurately your staff submits PA requests, and how completely your clinical documentation supports the requested service.
This means the operational levers for earning the gold card are all in the pre-submission workflow, not the post-denial workflow. A few specific factors drive high affirmation rates.
- Clinical documentation completeness at the point of care. If the provider notes fully support medical necessity for the requested service, PA approval is far more likely than if the notes are thin or generic.
- Accurate CPT and HCPCS coding on the PA submission. Mismatches between the requested service code and the documented clinical reason are one of the most common single reasons for PA denial or affirmation delay.
- Payer-specific documentation formatting. WISeR-participating vendors have specific documentation preferences for PA submissions. Practices whose submissions match those preferences see higher affirmation rates.
- Complete supporting documentation attached upfront. PA submissions with all supporting clinical documentation attached on first submission clear faster and more often than submissions requiring back-and-forth.
What Being Second Actually Buys You
WISeR is rolling out across the six pilot states on a staggered timeline through 2026. Practices in Washington were first. Arizona, New Jersey, Ohio, Oklahoma, and Texas are following on their own timelines. This staggered rollout creates a specific advantage for practices in the later-onboarding states: you can watch what worked for early-onboarding practices before your own assessment clock starts.
Specifically, the practices in Washington that hit the 90% threshold quickly generally did three things ahead of the pilot start:
- Audited their historical PA affirmation rate on the services WISeR would cover, to identify where their submissions were falling short of the threshold.
- Tightened clinical documentation workflows before the pilot started, particularly for the specific specialty and service categories WISeR was going to review.
- Built a clean PA submission process, often supported by their clearinghouse or a specialized PA workflow tool, that reduced first-submission errors before WISeR began measuring.
Practices in the later-onboarding states have the opportunity to run the same playbook on a longer runway.
The Downside of Missing the Threshold
Practices that do not hit 90% affirmation remain in the standard WISeR PA workflow, which carries its own operational burden. Every PA request goes through the AI-driven review pipeline. Denial rates on that pipeline, based on early Texas data, run around 38% on first pass (approximately 62% affirmation). Post-review approval improves the rate materially (approximately 84% affirmation after human review), but the burden of the review and appeal cycle sits with the practice.
The gap between being in the standard WISeR workflow and being exempt through the gold card is not marginal. It is the difference between doing PA for every affected service or doing PA for none of them.
How to Build for the Gold Card
For practices in the WISeR pilot states with traditional Medicare volume in the covered service categories, a few specific operational moves position you to hit and hold the 90% threshold.
- Baseline your current PA affirmation rate by service category. If you are already at or above 90% on the WISeR-covered services, your work is to maintain the standard. If you are below, you need to identify why.
- Tighten clinical documentation workflows for the covered service categories. Provider training, template updates, and clinical decision support prompts all move the affirmation rate.
- Use payer-specific PA submission tooling that formats documentation to WISeR-participating vendor preferences.
- Track affirmation rate monthly and investigate any dips. A single bad month can drop you below the threshold and require months to recover.
- Coordinate with your clearinghouse partner on PA workflow. Clean PA submission is not a solo effort; the infrastructure supporting it matters.
How Harris Secure Connect Supports Gold Card Operations
Harris Secure Connect’s PA submission workflow, payer-specific formatting, and Claims Correct AI scrubbing on PA request content are built to support the clean-submission discipline that gold card status requires. For practices in the WISeR pilot states, our infrastructure is designed to keep first-pass affirmation rates in the range that qualifies for exemption.
If your practice operates in a WISeR pilot state and wants to build systematically toward the 90% threshold, our team is happy to walk through what that infrastructure would look like for your specific specialty and service mix.