Accelerate prior authorization interoperability compliance with **proven APIs**

A scalable interoperability solution aligned with CMS-0057-F and CMS-0062-P to power your enterprise prior authorization strategy across medical services and medical benefit drugs.

Revisit CMS Readiness
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Revisit CMS Readiness

How Cohere Connect™ works

Partner with technology and UM experts

Cohere Connect was developed in partnership with clinical prior authorization experts to be configurable and support changing policies and frequently updated member requirements.

  • Deliver streamlined submissions

    Give providers the exact documentation requirements, configurable by procedure, diagnosis, place of service, and provider type.

  • Optimize administrative spending

    Give providers a platform that acts as an orchestrator for routing prior authorization requests across medical services and medical benefit drugs.

  • Support diverse policy requirements

    Address a broad range of policies, including CMS interoperability requirements, industry guidelines, and your custom medical policies.

Benefits

Key advantages of Cohere Health®

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

Interoperability

Drive interoperability across your medical service and drug PA workflow and reduce provider burden.

Compliance

One vendor for all the prior authorization FHIR APIs to support CMS-0057-F and CMS-0062-P.

Confidence

Ensure a sound DTR workflow with expert policy digitization services available across medical services and drug prior authorization.

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Automation

Leverage Cohere’s AI-powered platform to modernize automation and clinical decisioning while meeting compliance requirements.

Overview

Streamline provider connections & cut administrative costs

Our production-ready APIs are actively serving health plans nationwide. We not only meet HL7® Da Vinci™ Implementation Guide standards and support SMART® on FHIR® applications—we enhance them with essential capabilities that create truly efficient prior authorization workflows.

API

Purpose

Coverage Requirements Discovery (CRD)

Instantly verify if prior authorization is required and confirm service coverage.

Documentation Templates and Rules (DTR)

Intelligently gather and submit all required documentation for the request.

Prior Authorization Support (PAS)

Submit authorization requests and learn the outcome

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White paper

A strategic roadmap for clinical and medex optimization

AHIP’s deadline for 80% real‑time electronic approvals is coming quickly, and achieving it requires a new balance of care quality, operational efficiency, and provider experience. Health plans must accelerate approvals while maintaining medical expense discipline. Learn how to meet the mandate with a scalable, future‑ready strategy.

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Watch the Webinar

Webinar

Go beyond CMS-0057-F compliance

FHIR APIs alone don't guarantee accurate, provider-friendly prior authorization. See how policy digitization, AI-driven data extraction, and clinically intelligent automation turn static policies into code-ready, scalable workflows.

Illustration of two stacked books, one red and one blue, symbolizing knowledge, guidelines, or documentation.
Watch the Webinar
See Case Study

Case study

Explore the Humana experience

Humana partnered with Cohere Health® to transform prior authorization and improve patient care.

See Case Study

Beyond basic compliance: addressing prior authorization's hidden complexities

  • Automate provider guidance

    Give providers support to deliver the right information up front and adhere to rules with Cohere’s API-based process prompts

  • Digitize medical policies

    Improve the quality of medical necessity reviews with policy digitization services performed by interoperability and prior auth experts

  • Configure data connections

    Configure clinical documentation requirements based on procedure, diagnosis, site of service, and more

  • Centralize API endpoints

    Give providers compliant, API-based auth submissions where Cohere Health acts as an orchestrator–regardless of the vendor managing authorizations.

Validated impact

Cohere in action

Real results from payers and providers.

  • 93%

    provider satisfaction rating

  • 4000+

    digital policies supported

  • 15M+

    authorizations leveraging APIs

Modernize Your Prior Authorization Operations

API-ready utilization management solution by Cohere Health with medical policy digitization, reliable APIs, and streamlined provider connections
API-ready utilization management solution by Cohere Health with medical policy digitization, reliable APIs, and streamlined provider connections

**Don't force** compliance on legacy systems

While others scramble to adapt, our API-ready solution is already processing millions of authorizations.

Streamline Your Compliance
Streamline Your Compliance

Smarter UM starts with the right questions

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

Which health plans do the CMS prior authorization rules (CMS-0057-F and CMS-0062-P) apply to?

CMS-0057-F and CMS-0062-P (currently in proposed rule status) apply to the following plan types:

  • Medicare Advantage (MA)
  • Medicaid Fee-for-Service and Managed Care
  • Children's Health Insurance Program (CHIP) Fee-for-Service and Managed Care
  • Qualified Health Plans (QHPs) on the Federally Facilitated Exchange (FFE)

These rules do not apply to Commercial plans outside the exchange. However, it's worth noting that QHPs on the FFE are sometimes categorized under an organization's Commercial line of business, so impacted organizations should review whether their exchange-based plans fall within scope.

Additionally, some states are advancing their own prior authorization mandates that extend beyond the CMS rules and may apply to broader Commercial lines of business.

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What is CMS-0062-P and how does it relate to CMS-0057-F?

CMS-0062-P is a proposed rule that would extend electronic prior authorization and interoperability requirements to medical benefit and pharmacy benefit drugs, building on CMS-0057-F, which established these requirements for medical items and services. Key requirements are proposed to take effect in 2027. Cohere Connect's FHIR-native architecture and production-proven CMS-0057-F infrastructure position health plans to prepare for CMS-0062 requirements ahead of anticipated deadlines.

Beyond drugs, CMS-0062 also introduces new API usage reporting requirements for the Provider Access, Payer-to-Payer, and Prior Authorization APIs, expanding well beyond the Patient Access API metrics already required under CMS-0057. Plans would also be required to report their FHIR endpoints directly to CMS for centralized publication. Cohere Connect supports these provisions for the Prior Authorization APIs through its observability and reporting infrastructure.

Does Cohere Connect support prior authorization for medical benefit drugs?

Yes. Cohere Connect supports prior authorization workflows across both medical services and medical benefit drugs, including specialty and provider-administered therapies. Our APIs can be configured to handle drug-specific documentation requirements, clinical criteria, and routing—giving providers a single, compliant submission pathway.

Can Cohere Connect act as the orchestrator for all prior authorization submissions for CRD, regardless of the entity performing reviews and determinations?

Yes, Cohere Connect can be configured to act as the orchestrator for your providers’ prior auth submissions.

How is the requirement for mandatory X12 278 transmissions impacted by CMS-0057-F?

In response to CMS-0057-F, the National Standards Group will not take HIPAA Administrative Simplification enforcement action against HIPAA covered entities that choose not to use the X12 278 standard as part of an electronic FHIR prior authorization process.