CMS Records Show It Pressed Four Medicare AI Prior Authorization Vendors Over Backlogs, Portals and Questioned Denials

Letters from the WISeR Model Team at CMS show the agency pressing four of the technology contractors that run prior authorization in its Original Medicare model between January and March 2026: Innovaccer, Genzeon, Virtix Health and Zyter. The letters open a file posted by the Electronic Frontier Foundation on October 27 in its Freedom of Information Act lawsuit against CMS.

CMS’s January 7 request for a corrective action plan from Innovaccer, the Ohio contractor, rests on the company’s December 2, 2025, email. Innovaccer had written it would “not have a portal live by the January 5th Go Live Date” and was still setting up its provider phone line. CMS called that noncompliance and asked for a plan acknowledging it, with steps, timeframes, responsible officials and milestones. Innovaccer’s plan promised a portal by February 5. The February 20 Performance Notice of Non-Compliance records a “limited launch” the next day “with a selected group of providers” and states that Innovaccer “has therefore violated Section 13.1(A)(3)” of the participation agreement.

The notice lists steps CMS may take if deficiencies go uncorrected: additional monitoring or audits, “withholding, denial, or recoupment of WISeR Payments”, suspension of prior authorization work, and termination from the model. A reissued request that day set March 5 for a portal open to all providers and suppliers in Ohio and said CMS would require documentation that the plan was implemented. It puts withholding in firmer terms: if Innovaccer fails to submit or carry out the new plan, or CMS rejects it, that “will result in payments being withheld”.

The other three letters are requests for information. Each says CMS “is concerned with” the contractor’s “alignment” with the agreement and asks for causes, without finding a breach. The February 6 letter to Genzeon cites an email received by a Medicare Administrative Contractor (MAC) that listed cases outstanding as of January 27, among them 459 awaiting a decision letter from Genzeon, and notes duplicate Unique Tracking Numbers. Genzeon’s February 13 reply blamed, among other causes, the esMD electronic submission system being unavailable and a race condition in its own code that duplicated submissions.

CMS’s February 27 letter to Zyter cites emails received by a MAC and the esMD contractor reporting invalid submissions, missing tracking numbers and late decision letters. Zyter had disclosed sending no determination letters as of February 18. As we read CMS’s six letters, only this one cites Section 3.4(B), under which a contractor “shall use its Enhanced Technology” to support “accurate and timely coverage determinations”. It does not say whether Zyter’s technology fell short, or in what way. It also cites Section 3.6(A)(3), on overseeing clinicians and clinical reviewers, which may include auditing their denial and affirmation rates. Our September report set out the model’s rule: every non-affirmation must have medical review, and whichever WISeR clinician or clinical reviewer does it must be licensed. Zyter’s March 5 reply says the problems were technical, were resolved by February 28 and “did not affect the clinical review process or determination outcomes”.

CMS’s March 17 letter to Virtix Health rests on “multiple provider complaints”, including “denials that appear inaccurate or inconsistent with applicable criteria”. CMS asks Virtix to explain determinations “that may have been issued in error or required clarification”. The letter makes no finding that any denial was wrong.

EFF says the documents show a rollout that was “rushed and rocky from the start”. In our reading, apart from the Virtix complaints and the Zyter letter’s technology and clinician-oversight clauses, the rest concern operations: portals, backlogs, tracking numbers and decision letters. They do not assess the contractors’ AI, the wider subject of our health claims analysis.

CMS’s six letters stop at requests, warnings and one Performance Notice; none records a payment withheld, a suspension or a termination. The file’s readable pages do not show what Virtix said in answer, how CMS answered the replies, or whether Innovaccer met the March 5 date.