Cohere Health

Cohere Health provides AI-driven clinical intelligence solutions designed to streamline utilization management (UM) and payment integrity (PI) operations for health plans. The company offers its Cohere Unify platform to automate prior authorization workflows, reduce administrative burden, and improve clinical decision-making accuracy. Their solutions are available as platform-only offerings for in-house teams, fully delegated services with clinical staff, or API-based integrations compliant with CMS-0057-F interoperability requirements.

The company's approach combines clinically trained AI with transparent decision-making processes to address both utilization management and payment integrity challenges. For UM, Cohere reports automating up to 90% of prior authorization decisions while reducing clinical review time by 35-40%. On the payment integrity side, the platform identifies inappropriate payments through AI-powered audits, delivering reported efficiency gains of 30% for auditors and 14% improvement in audit hit rates.

Cohere Health holds HITRUST and NCQA accreditations and serves major health plans including Humana and Geisinger Health Plan. The company has received multiple industry recognitions, including KLAS Points of Light awards in 2022 and 2024, and has been listed on LinkedIn's Top Startups and CB Insights Digital Health 150.

Consider Cohere Health if your health plan is struggling with prior authorization backlogs, provider satisfaction issues, or legacy payment integrity vendor dependencies. The platform excels at organizations ready to adopt AI-driven automation while maintaining clinical oversight and transparency in decision-making.

Expect a phased implementation that can start with specific service lines or departments, with flexibility to expand from platform-only adoption to fully delegated operations. The company's emphasis on provider satisfaction metrics suggests strong focus on reducing friction in payer-provider interactions while maintaining utilization controls.

Cohere Health operates exclusively in the health insurance and payer segment of healthcare, with 100% focus on health plan operations. The company addresses payer-specific challenges including CMS regulatory compliance (specifically the CMS-0057-F Interoperability and Prior Authorization Final Rule), NCQA utilization management standards, and payment integrity requirements unique to health plans. Their clinical intelligence approach incorporates medical necessity determinations, peer-to-peer physician reviews, and coding validation specific to health plan adjudication processes.

The ideal client is a regional or national health plan with 100,000+ members seeking to transform prior authorization processes beyond legacy systems. Organizations experiencing high provider abrasion, lengthy authorization cycles, or dependency on opaque payment integrity vendors will find the most value. Best suited for plans with internal UM teams ready to adopt AI augmentation or those seeking fully delegated specialty-specific UM operations.