Prior authorization & UM · Prior authorization review software for health plans
Cohere Health
Cohere Health is a Boston company, founded in 2019, that builds artificial intelligence software for prior authorization and utilization management, the approvals insurers require before certain care. The software checks each request against the plan's written criteria and approves routine ones in real time, and nurses and physicians review the rest. Doctors file through a web portal or from their EHR, and the same clinical rules extend to claims payment checks, appeals, care management, and quality reporting.
Strong fit
- Regional and national health plans that review prior authorization in volume and want AI to clear routine requests while clinicians handle the rest
- Plans preparing for federal electronic prior authorization rules (CMS-0057-F) that want FHIR-based interfaces for provider and payer data exchange
- Plans that want claims payment checks, appeals, and quality reporting built on the same clinical criteria as their prior authorization decisions
Weak fit
- Provider groups looking for their own tool to file and track authorizations, since Cohere Health contracts with plans and providers meet it only through a plan's portal
- Small plans that want to start on their own, since rollouts involve a contract, policy work, and provider onboarding
- Teams that need independent outcome data, since most results come from Cohere Health and its customers
Bottom line
Cohere Health is a good choice for a health plan that wants one vendor to take in prior authorization requests, approve the routine ones automatically, and keep clinicians on the hard cases, and Humana's multi-year rollout gives it a large reference customer. Nearly all outcome figures are company-published, and implementations can run up to six months, according to Keragon. Providers cannot buy it directly.
Score breakdown
Weights: Outcomes 35% · Product 30% · Implementation 20% · Pricing clarity 15%.
Cohere Health serves health insurers. A plan licenses the software to receive prior authorization requests from doctors, decide the routine ones in real time, and route harder cases to its own reviewers or to Cohere's clinical team. The best-matched jobs are outpatient and inpatient prior authorization, medical-benefit drug reviews, and add-ons for claims payment checks, appeals, care management, and quality reporting.
On price, no figure is published, and the other plan-side products in this category, including Xsolis, Availity AuthAI, Itiliti Health, and Myndshft, are quote-based as well. Provider-side tools such as Keragon, which lists plans from $149 a month, cover the doctor's filing work, a different job from the plan's review work.
The closest competitors are Anterior, Xsolis, Humata Health, Availity, Itiliti Health, and Banjo Health, and Myndshft is one more that Keragon lists.
Cohere Health was founded in 2019, according to the company's July 16, 2025 release. Siva Namasivayam is chief executive and co-founder, Krishna Kottapalli is chief growth officer, and Brian Covino, MD, is chief medical officer. Robert Shepardson, a former Morgan Stanley investment banker and Amwell chief financial officer, joined as chief financial officer in October 2024. The company is private. It announced a $90 million Series C on May 14, 2025, led by Temasek with Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners taking part, and put its total funding at $200 million. On September 9, 2025, it announced the acquisition of ZignaAI, a payment integrity company, to add claims payment checks.
Day to day, a doctor's office sends a request by web portal, phone, or fax, or starts it inside the EHR, and Cohere's software pulls the clinical details from the attached records and compares them with the plan's criteria. Requests that meet the criteria are approved on the spot. Requests that do not are pended for a nurse or physician, and Cohere says its AI is never used to deny care. The company's own figures are 17 clients, 25 million covered lives, 47 million plan and provider interactions, 85% of requests approved in real time, and 94% provider satisfaction. Real-time approval rates run from 50% to 90% depending on the specialty, according to its comparison page, which also claims more than 50% fewer overturned denials than prior vendors. The fullest reference is Humana. A case study dated August 2026 says the program began in January 2021 and now covers 5.1 million Medicare Advantage and commercial members in all 50 states, with 95% provider portal adoption, an 89% auto-approval rate, and 5 days cut from the time to a requested service.
On connections, Cohere's platform page lists native integrations with Epic, Rhyme, Availity, and NaviNet and FHIR APIs for CMS-0057-F, and an April 3, 2024 release announced the Epic Payer Platform integration that lets providers start a request in their EHR workflow. RevCycleAI adds that Oracle Health (Cerner) and Meditech connect through FHIR-based APIs. The platform is HITRUST r2 certified, a status announced on August 17, 2022, and the company says it was the first digital prior authorization platform to earn utilization management accreditation from NCQA. Switching later is heavy, since RevCycleAI describes it as rebuilding clinical guidelines, retraining staff, and migrating provider connectivity over a multi-year project.
Customers quoted by Cohere Health praise the portal, the speed of decisions, and the results. A quote on its provider page credited to Fyzical Therapy & Balance reads: "I have loved it since I began using it. The portal is easy to navigate, the decisioning is quick…" Another, credited to the University of Tennessee Medical Center, reads: "I love the portal, it is one of my favorites. Very user friendly and precise. The portal lets me know what I need." On its platform page, Cohere Health quotes William Shrank, MD, MSHS, who was Humana's chief medical officer when the quote was released in October 2021: "The results of Cohere Health's digital authorization platform have exceeded our expectations."
"I never picked Cohere. My plan did, so when a request stalls I am learning that plan's portal rules and still filing everything myself."
"Up to six months to get live is a long wait when the whole point is fewer faxes and phone calls."
Where customer reviews couldn't be found, our analysts attempted to give a voice to buyer sentiment, drawing on real information from review sites, forums, and product documentation. Based on: RevCycleAI, Keragon, and Flexbone.
Independent coverage points to opaque pricing, long implementations, and Medicare's WISeR program. RevCycleAI, an April 2, 2026 deep dive, lists a payer-side product that providers cannot choose and pricing opacity that makes evaluation hard without a full demo cycle among its cons. Keragon, a vendor of provider-side prior authorization tools, says implementations run up to six months. Medscape's April 6, 2026 report on Medicare's WISeR prior authorization program calls Cohere Health the vendor for Texas. WISeR assigns one contractor to each of six states, and the physicians Medscape quotes on delays and denials practice in Arizona and Washington, so their complaints concern other vendors. A Cohere spokesperson told Medscape that its technology is "never used to deny care but rather to automate approvals."
Anterior builds clinical AI that reviews prior authorization requests for health plans against plan guidelines, approves clear cases in minutes, and prepares the rest for nurse review. Xsolis suits providers and payers that want AI behind patient status and utilization review, Humata Health works for health systems and payers that want records gathered and requests submitted and tracked, and Availity is a broad payer connectivity network whose AuthAI product offers explainable authorization decisions. Itiliti Health targets plans and providers that want payer medical policies turned into electronic authorization workflows, and Banjo Health serves plans and pharmacy benefit managers with prior authorization, appeals, and criteria automation.
Competitor landscape
| Vendor | Overall | Ease of implementation |
|---|---|---|
| Anterior | 8.1 | 8.1 |
| Xsolis | 7.8 | 7.3 |
| Humata Health | 7.7 | 7.4 |
| Availity | 7.5 | 7.3 |
| Itiliti Health | 7.3 | 7.1 |
| Cohere Health | 7.2 | 6.6 |
| Banjo Health | 7.2 | 7.0 |
Pricing
| Item | Detail |
|---|---|
| Model | A contract with the health plan. Cohere's comparison page describes an "admin fee pricing model that avoids incentivizing denials," and RevCycleAI describes per member per month or per authorization fees. |
| What usually drives cost | Plan membership and authorization volume, which RevCycleAI says contract fees scale with. |
| What to ask before you buy | Whether fees are per member or per authorization, what implementation and policy codification cost, which modules are in scope, and how long go-live takes. |
| Published pricing | Cohere Health publishes no prices, and RevCycleAI reports the same. |
Prerequisites for purchase
| Need | Why it matters |
|---|---|
| What you need to get Cohere Health to function | |
| A health plan or delegated entity that owns utilization management | Cohere Health contracts with plans, so a provider group cannot adopt it alone. |
| Medical policies in a form the software can apply | Real-time approvals depend on written criteria, and Cohere offers codification of national, local, third-party, and custom policies. |
| Clinical reviewers for requests the AI does not approve | Pended requests go to a nurse or physician, from the plan's staff or Cohere's clinical team. |
| IT capacity for FHIR and EHR connections | Cohere Connect runs on FHIR standards, and Keragon puts implementations at up to six months. |
| A plan to move network providers onto the portal | The company's adoption and satisfaction figures depend on providers using it. |
| What will maximize your value | |
| Start with one specialty program, such as musculoskeletal or imaging, before widening | Real-time approval rates run from 50% to 90% by specialty, so early results show where tuning is needed. |
| Track overturned denials and call volume against the prior vendor | Cohere reports more than 50% fewer overturns and a 64% reduction in call volume, and a plan can test both on its own data. |
| Post review criteria where providers submit | Cohere's provider page promises "full visibility into approval criteria and clinical guidelines" to providers who file requests. |
| Send every non-approval to a clinician for review | This keeps decisions with people, which matches what Cohere says about its AI. |
| Add claims payment checks after authorization is stable | Cohere's payment integrity suite applies clinical review to claims before they are paid, and two changes at once blur which one moved results. |
| Deal-breakers | |
| You are a provider group that wants to buy it directly. Providers meet Cohere only through the plans that adopted it. | |
| Your plan expects AI to issue denials with no clinician review. Cohere says its AI automates approvals and board-certified clinicians review complex cases. | |
| No one owns the clinical criteria the AI applies. Without an owner, nothing keeps them current. | |
Value creation time frame
| # | Stage | Typical range |
|---|---|---|
| 1 | From contract to go-live | Up to six months, according to Keragon |
| 2 | From go-live to provider adoption | Within a month of the January 2021 launch, adoption passed Humana's goal, and Cohere Health's August 2026 Humana case study reports 95% provider portal adoption |
| 3 | Switching to another vendor later | A multi-year project, according to RevCycleAI |
Leadership
- Siva NamasivayamCEO and co-founder
- Krishna KottapalliChief growth officer
- Robert ShepardsonChief financial officer
- Brian Covino, MDChief medical officer
Methodology
| Weight | Factor | What it measures |
|---|---|---|
| 35% | Customer outcomes | Whether buyers get measurable operational or clinical-workflow results after go-live |
| 30% | Product | Capability depth, reliability, and fit for the job the category buys |
| 20% | Implementation | How hard it is to stand up, integrate, train, and stabilize |
| 15% | Pricing clarity | Whether a buyer can model total cost without a mystery quote |
| Label | Meaning |
|---|---|
| Highly recommend | Strong outcomes and product with manageable caveats |
| Recommend | Solid fit for the right buyer; know the tradeoffs |
| Conditional | Only with a specific use case or heavy caveats |
| Not recommended | Avoid for most buyers in this category |
Read our full methodology for how we weight scores and assign recommend labels.