Cohere Health

A reported 350 or more clinically trained models perform the determination itself. Auto approving 85 percent of prior authorization requests in real time is not achievable with rules alone, and the models are what the plan is buying.

The most important design disclosure in this category, and it turns on direction rather than degree. The AI auto approves; it does not auto deny. The company states that up to 85 percent of submissions receive real time approval and that the remaining submissions are reviewed by a clinician before final determination. That asymmetry is the correct architecture for prior authorization: an erroneous automated approval costs the plan money, while an erroneous automated denial costs a patient care, and only one of those should ever be delegated to a model. Buyers and regulators should verify the asymmetry holds in contract and configuration, since it is the entire safety argument.

Volume and outcome evidence are both substantial and specific: more than 15 million prior authorization submissions carried through the APIs, 47 million payer provider interactions annually, care access reported 70 percent faster than traditional processes, up to 9x return on investment, and 50 percent faster inpatient and outpatient reviews. Provider satisfaction is measured from the counterparty rather than the customer, at 94 percent with an NPS of 67, which is unusual and meaningful: a payer tool that providers rate well is evidence the automation is not simply obstructing care. Named plan relationships include Humana and Geisinger.

Governance surface is real but thin relative to the stakes. The company positions itself around decision transparency and full auditability, supports CMS-0057-F electronic prior authorization compliance, and joined the CMS Electronic Prior Authorization Acceleration initiative, which is regulatory alignment rather than model governance. Third party commentary raises the standing concern that models trained on historical authorization data can reinforce existing patterns of denial, and no bias evaluation, subgroup performance analysis, or independent audit was retrieved to address it. For a system making coverage determinations at this volume, that is the most consequential gap in the record.

Multi channel by design and deliberately undemanding of the provider: submissions accepted by phone, fax, and web intake as well as direct EHR integration, with mature APIs supporting CMS-0057-F compliance. Meeting providers on legacy channels rather than requiring integration is what allows a payer side product to reach the whole network rather than only its digitally mature members.

No public pricing. Contact the vendor. Enterprise agreements with health plans, with flexible deployment models and an outsourced utilization management option. The return on investment framing, cited between 8x and 18x depending on product, implies savings linked economics; buyers should establish whether compensation scales with denials or with cycle time, since those create opposite incentives.