Cohere Health Commends AHIP and CMS for Unified Industry Action on Prior Authorization Reform

Cohere's Utilization Management Suite, Clinical-grade AI, and Clinical Experts Support Health Plans in Reaching Key Goals

BOSTON, June 24, 2025 /PRNewswire/ -- Cohere Health^®, the leader in clinical intelligence solutions for health plans and risk-bearing providers, commends the parallel announcements by AHIP, HHS, and CMS outlining industry-wide commitments to improve the prior authorization (PA) process. The pledge by major health plans to reduce administrative burden, improve transparency, and accelerate access to care marks meaningful progress toward a more efficient and collaborative healthcare system.

The parallel announcements outline clear, measurable goals, including the adoption of FHIR^®-based APIs, making real-time decisions for at least 80% of requests with clinical documentation, improved communication and transparency around determinations, and a narrowed scope of services subject to prior authorization. Cohere is already delivering on or exceeding these objectives for health plans and their members nationwide, with real results across speed, efficiency, precision, and provider satisfaction, including:

• 85% of prior authorization approvals in real time
• 9 million authorizations leveraging FHIR APIs in the last year
• 61% reduction in provider input time
• 50% faster medical necessity reviews with over 99% precision using artificial intelligence (AI)-enabled applications
• 100% use of relevant sub-specialist, board-certified physicians in the loop for clinical AI algorithms and final determinations
• 93% provider satisfaction across more than 600,000 providers supported

"Since 2019, Cohere has championed real-time authorization and improving the provider and patient experience using native-AI algorithms and FHIR API standards, and we support these changes," said Siva Namasivayam, CEO and co-founder of Cohere Health. "CMS endorsing this pledge signals a clear, industry-wide mandate to modernize prior authorization. This commitment reflects the kind of transformation the healthcare industry needs and that patients and providers deserve."

Delivering the future of prior authorization

The Cohere Unify™ platform and the company's Utilization Management Suite combine evidence-based clinical guidelines, expert medical oversight, and precision AI to automate and improve the PA experience with greater transparency. It supports provider submissions across EHRs, phone, fax, and portals, and is already live with FHIR-based electronic prior authorization (ePA), enabling more consistent, streamlined submissions and faster decisions.

The platform also provides real-time, context-aware guidance to help ensure requests are complete at the point of submission. A dynamic clinical rules engine adjusts to the care setting, whether preventive, episodic, or emergent, and is continuously updated by board-certified physicians. Providers with consistent approval records benefit from personalized workflows through Cohere Align™; unlike traditional gold carding programs, which may bypass reviews, Cohere's approach maintains clinical oversight while streamlining workflows for high-performing providers.

Precision AI informed by clinical expertise

Cohere's AI is designed to support and accelerate approvals; it is never used to deny care. All non-approved requests are reviewed by licensed medical professionals. The platform's models are trained on both unstructured and structured clinical data, including provider notes, and are guided by established medical policies and clinical best practices. This allows for more accurate decision support based on patient-specific nuances and real-world practice.

Cohere recently surveyed 100 clinicians and 100 office professionals involved with prior authorization and found 99% of clinicians and 96% of administrators trust AI when used appropriately in the PA decision-making process. Cohere's expert Medical Advisory Board and robust clinical strategy teams oversee the development of its decision logic to ensure technology remains a tool that supports, rather than replaces, provider judgment.

Smarter scope management and ongoing optimization

While the number of clinical codes is not the challenge in prior authorization, provider abrasion and care delays often stem from areas where medical necessity and patient safety issues are frequently questioned. Cohere helps health plans improve PA in areas with high clinical variation in care. Its platform captures data across the full authorization lifecycle, identifying friction points like repeat submissions and avoidable denials. These insights allow plans to refine which codes truly need PA, adjust policies over time, and continuously optimize to improve efficiency,  provider experience, and patient safety.

As the healthcare industry embraces a new phase of prior authorization reform, Cohere is already delivering on the outcomes that CMS and AHIP's member plans are working to achieve. The company remains committed to helping health plans, providers, and patients build a more efficient, transparent, and equitable system of care.

Learn more at coherehealth.com.

About Cohere Health 
Cohere Health's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving collaboration between physicians and health plans. Cohere works with 600,000 providers and processes millions of prior authorization requests annually. Its AI auto-approves up to 90% of requests for millions of health plan members. Cohere has been recognized in the Gartner® Hype Cycle™ for U.S. Healthcare Payers in 2024 and 2025, named a Top 5 LinkedIn™ Startup in 2023 and 2024, and is a three-time KLAS Points of Light award recipient.

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SOURCE Cohere Health