Accelerate prior authorization compliance with **proven APIs**

A mature, scalable solution ready to address your CMS-0057-F needs today.

Get CMS Ready
Illustration showing a 3-step process with icons: coverage requirements discovery (clipboard with magnifying glass), documentation and rules (gear), and prior authorization support (speech bubble).
Get CMS Ready

The Clock is Ticking: Solving Complex Prior Authorization Challenges

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 single front door for routing prior authorization requests.

  • Support diverse policy requirements

    Address a broad range of policies, including CMS, 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 PA workflow and reduce provider burden.

Compliance

One vendor to comply with the Prior Authorization APIs for CMS-0057-F.

Confidence

Ensure a sound DTR workflow with policy digitization services included.

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

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, without error-prone questionnaires

  • 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 a single front door for compliant, API-based auth submissions–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

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.

What health plans does the CMS prior auth rule (CMS-0057-F) apply to?

CMS-0057-F Applies to Medicare Advantage, Medicaid, and CHIP Fee-for-Service as well as Managed Care and Qualified Health Plans (QHPs) in the Federally Facilitated Exchange. It does not apply to Commercial plans, however some states are pushing forward with similar mandates that apply beyond the CMS prior auth rule’s scope to include Commercial lines of business.

Do health plans need to have an existing arrangement with Cohere for prior authorization in-house automation or delegated clinical specialty management in order to benefit from Cohere Connect?

No, Cohere Connect is a standalone offering from Cohere that does not require the purchase of in-house automation or delegated prior auth solutions. Cohere Connect can empower health plans to quickly achieve compliance with the FHIR API workflow requirements of CMS-0057-F.

Can Cohere Connect act as the “single front door” 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 single front door 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.