What is agentic AI and why it matters for health plans

Health plan leaders face mounting pressure to cut administrative costs, drive growth, and enhance patient outcomes, all while navigating a labyrinth of complex regulations. Meanwhile, fragmented workflows and manual processes continue to create delays for providers and patients.

That’s where agentic AI in healthcare comes in.

Momentum is accelerating quickly–61% of healthcare organizations are already building or budgeting for agentic AI, and 85% plan to increase investment over the next two to three years

The shift from generative AI to agentic AI in healthcare

Generative AI tools, typically powered by large language models (LLMs), are engineered to produce text. In the context of healthcare, these tools can be used to summarize clinical documentation, draft prior authorization letters, and assist with appeals and other communications. While these capabilities are undoubtedly valuable, they do not fully complete the required tasks.

Agentic AI marks a significant leap forward in healthcare, an evolution Deloitte says is already in progress. This advanced form of AI is set to do more than just optimize individual tasks. It's poised to fundamentally reshape healthcare operating models and redefine how the entire industry functions.

This advanced AI can:

• Make context-aware decisions using clinical and operational data, with appropriate clinical oversight for higher-risk scenarios
• Orchestrate complex, multi-step workflows across various systems
• Execute tasks end-to-end, from initial intake to final resolution

Why agentic AI is becoming essential for health plans

The core challenge in healthcare isn't a lack of information, but a breakdown in workflow. This is precisely where agentic AI can make a significant impact. 70% of health plans are prioritizing agentic AI for utilization management, prior authorization, and claims processing–the areas with the highest administrative burden and operational complexity.

In addition to regulatory requirements such as CMS-0057-F, the industry is accelerating toward modernization. Initiatives such as the AHIP prior authorization commitments reflect a broader push among health plans to improve transparency, reduce unnecessary administrative burden, and streamline prior authorization workflows. This industry-wide alignment underscores a critical shift: modernization is no longer optional or isolated.

Key use cases for agentic AI in healthcare

1. Automating prior authorization at scale

Prior authorization remains one of the most resource-intensive processes in healthcare. Agentic AI transforms prior authorization by:

• Digitizing intake across fax, portal, and EHR integrations
• Extracting only the minimum necessary clinical data
• Applying evidence-based medical policies in real time
• Automating approvals and routing exceptions appropriately

With an intelligent platform like Cohere Health’s, health plans have seen real-time approval rates reach up to 85%, helping reduce provider abrasion and accelerate patient access to care.

Early deployments across the industry already demonstrate impact–reclaiming thousands of clinical hours and significantly reducing manual review volume.

2. Transforming payment integrity operations

Payment integrity (PI) is often fragmented across vendors and workflows, limiting visibility and missing opportunities to proactively control costs.

Agentic AI enables:

• End-to-end clinical and coding audit reviews and decisioning
• Autonomous data mining for overpayment detection
• Dynamic data mining rule creation, optimization, and maintenance

This shifts PI from a siloed, retrospective process to a unified, proactive cost containment system, helping plans identify, validate, and act on savings earlier and at scale.

3. Enabling compliance with CMS interoperability mandates

Under the new CMS-0057-F rule, health plans must automate prior authorization workflows, offer real-time status updates, and facilitate data exchange through APIs.

Rather than viewing this as a mere compliance task, health plans can leverage agentic AI to help establish a scalable digital framework that drives future innovation.

Why health plans are partnering with Cohere Health for agentic AI

Cohere Health’s platform is designed to provide agentic AI in healthcare, combining:

• AI developed in partnership with clinicians and grounded in real-world prior authorization decisions.
• Evidence-based guidelines developed and validated by practicing physicians.
• Transparent, auditable decision-making designed to support health plan compliance obligations.

Unlike general-purpose AI, Cohere Health’s platform is designed specifically for healthcare operations. It provides the shared clinical context and data to power both integrated and standalone agentic solutions. These solutions span policy management, UM, payment integrity–with care management, appeals, quality improvement, claims, and other use cases fast-approaching.

With flexible deployment models, health plans can:

• Modernize their in-house utilization management
• Delegate specific service lines
• Scale automation across the entire enterprise

The future of healthcare is agentic

Agentic AI is already reshaping healthcare, moving from a future concept to a present-day reality for leading health plans. While nearly all healthcare executives anticipate significant cost savings and actively invest in this technology, its impact extends far beyond efficiency.

If you’re evaluating how to bring agentic AI into your organization, start by identifying where manual workflows create the most friction–especially in prior authorization and utilization management.

Explore how Cohere Health's AI supports clinicians, informs IT leaders, and improves outcomes for patients.