Outsourced utilization management for precision medex savings

Driving better care decisions and outcomes through expertise, not denials.

Scale Utilization
Scale Utilization

Cohere Complete™ provides fully delegated, end-to-end utilization management operations across key specialties

Unlike legacy outsourced services, we deliver medex savings through efficiency that supports lowering provider abrasion and getting members faster access to care. Our technology-enabled approach integrates advanced AI, real-time analytics, and deep clinical expertise.

  • Build trust with providers and members by prioritizing efficient by automating approvals

  • Free your team to focus on complex clinical areas

  • Leverage scalable and composable offerings to evolve your UM operations over time

  • Configure provider experiences based on performance metrics

Specialties we manage

We offer fully-delegated management services for key clinical specialties

Musculoskeletal

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Cardiology

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Physical therapy

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Sleep

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Diagnostic imaging

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Interested in additional specialties?

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Benefits

Key advantages of Cohere Health®

Cohere streamlines the prior authorization process, making it efficient and effective. With our platform, health plans can leverage automation to enhance clinical decision-making.

Move beyond denial-based approaches to drive medex savings

63% of Cohere's impact comes from non-denial interventions that reduce care delays and provider frustration.

Transition to precision AI-driven care quality improvement

Our clinical intelligence platform leverages provider workflow nudges and advanced LLMs to support up to 90% auto-approval rates.

Reduce friction with a best-in-class provider experience

Provider-loved experience (93% satisfaction) with EHR interoperability and reduced requirements for high-performing physicians.

Overview

The Cohere Complete difference

With more than 130 on-staff nurses and physicians supported by powerful, AI-driven technology, our end-to-end approach bridges the gap between fragmented authorization transactions and comprehensive clinical care management.

Proven ROI methodology

Measurable medex savings

  • Proven results of >50% fewer overturns versus prior vendors due to preventing missing information denials with technology–PA decisioning that is right the first time
  • Up to $4.56 PMPM non-denial medical expense savings (delegated cardio UM for national health plan)
  • Admin fee pricing model that avoids incentivizing denials

Provider focused experience

Industry-leading and publicly documented provider experience:

  • 40% reduction in provider time spent on authorizations
  • 93% provider satisfaction rate due to simplified digital workflow
  • 96% provider digital adoption rates

Tested and trusted AI

Clinical intelligence and responsible AI engine

  • Peer-to-peer and denial determinations made by same-specialty physicians, not AI
  • Clinically trained AI fine-tuned by medical specialty and business rules enables instant approvals for clinically appropriate care
  • AI can extract unstructured clinical data from attachments, which ensures high-quality decisioning

Clarity around compliance

Transparent operations & compliance

  • Real-time reporting through technology system integration to ensure clients see the same data that Cohere teams analyze
  • Additional compliance support for a single API for all in-house and delegated UM based on CMS-0057-F compliance requirements
  • Partnership in business planning and ongoing performance reporting

Deep clinical expertise

Experienced clinical teams

  • Deep on-staff bench of specialized nurses and physicians representing all managed specialties
  • Same sub-specialty peer-to-peer reviews for denial determinations
  • Compliant and above average TAT (3 days) on manual commercial authorizations

Fundamentals

6 core components of Cohere Complete

Cohere is delegated for millions of prior authorizations per year with experience that drives provider satisfaction:

  • Intake

    Best-in-class authorization submission experience through multiple channels (Phone, Fax, EMR, Cohere application).

  • Automated decisioning

    Real-time decisioning based on clinically trained AI fine-tuned by medical specialty and business rules.

  • RN/LPN review

    Cohere’s on-staff RNs and LPNs conduct reviews.

  • Missing info outreach

    Delegated operations team conducts outreach to provide an opportunity for approval.

  • MD and peer-to-peer review

    Same-specialty peer-to-peer review powered by guideline education and partnership.

  • Decision and notification

    Delivered through a timely, compliant process.

Why health plans choose Cohere Complete

  • Expertise without abrasion

    Our delegated services deliver results without the provider frustration typical of legacy vendors.

  • MLR-attributable fees

    As a quality improvement program, Cohere fees are attributable to MLR.

  • Transparent partnership

    Self-service dashboards and proactive service management rather than "black box" operations.

  • Dedicated clinical teams

    Specialized physicians and nurses focused exclusively on your members' care needs.

Fully delegated UM—without the friction

Drive clinical quality and efficiency through expert-led, AI-powered utilization management that builds trust, not abrasion.

Scale Utilization
Scale Utilization

Smarter UM starts with the right questions

Explore common questions about Cohere’s fully delegated utilization management services.

How does Cohere's delegated UM approach differ from traditional vendors?

Unlike traditional vendors who rely on denials for savings, 63% of Cohere's impact comes from non-denial interventions like pre-submission nudges and care path guidance. We focus on directing providers to optimal, clinically appropriate care that can be auto-approved rather than denying services after submission.

What makes Cohere's provider experience superior to other delegated UM services?

Cohere achieves a 96% digital adoption rate and 63 Net Promoter Score through our intuitive platform, real-time decisioning, and reduced administrative burden. Providers spend 40% less time on authorizations and make 64% fewer support calls to the health plan.

How do you ensure clinical quality in your delegated UM services?

Our clinical decisions are guided by evidence-based policies, including NCDs and LCDs, third-party policies, custom policies, and policies developed in partnership with leading medical societies. All peer-to-peer reviews and denial determinations are conducted by same-specialty physicians, and our clinical teams undergo a rigorous 30-day training program.

What specialties can Cohere manage through delegated UM?

We currently provide delegated UM for musculoskeletal, cardiology, diagnostic imaging, gastrointestinal, and sleep medicine, with additional specialties coming soon.

How does Cohere ensure appropriate turnaround times for authorization decisions?

Cohere is a market leader in turnaround times, with 90% of authorizations approved instantly and an average 3-day TAT on manual commercial authorizations. Our real-time missing information detection reduces documentation gaps by 25% and speeds decisioning time by 40%.