Modernizing complex audits: How health plans can improve accuracy with Cohere Validate™

With more members living with complex comorbidities, health plans are facing a growing volume of complex claims. The majority of health plans, however, rely on costly legacy vendors that lack transparency and control. 

The result? Slow processing times, provider abrasion, compliance risk, and financial leakage. In fact, claims processing inefficiencies account for an estimated 15 cents of every healthcare dollar, putting pressure on already thin margins. To keep pace, more health plans are rethinking how complex claims are managed—and increasingly bringing high-value reviews in-house with technology that balances automation and human expertise.

The rise of complex claims in healthcare

Complex claims are fundamentally different from routine claims. They often involve lengthy medical records, multiple diagnoses and procedures, and evolving clinical guidelines. The challenge isn’t just volume—it’s precision. Legacy vendor solutions typically rely on opaque rule engines and manual workflows, making it difficult for health plans to understand why decisions are made, adjust review logic, or confidently stand behind outcomes. As regulatory scrutiny increases and provider relationships matter more than ever, these opaque approaches are no longer sustainable.

It’s no surprise that 97% of health plans say gen AI and agentic AI will add value to prior authorization and claims processing in 2026. But not all AI is created equal. Accuracy, auditability, and clinical oversight are essential for complex claims.

Introducing Cohere Validate™

Cohere Validate is an AI-powered clinical and coding validation solution designed to help health plans modernize complex claims management by bringing it in-house, while maintaining a focus on accuracy, efficiency, and compliance.

Part of our Payment Integrity suite, Cohere Validate combines transparent AI with human-in-the-loop safeguards, enabling health plans to gradually take greater control of their most challenging claims reviews through flexible in-house, hybrid, or service-supported models while reducing reliance on costly, inflexible vendors.

Cohere Validate supports complex claims at scale through:

Comprehensive coverage
Automated prospective and retrospective reviews across inpatient, outpatient, and professional claims help address the most clinically and financially complex scenarios.

Refined selections
Using UM and PI data, the solution enables smarter prioritization, enabling more efficient, accurate decision-making.

AI-powered validation with human oversight
Advanced AI, NLP, and ML intelligently identify claims, validate clinical evidence, and cross-reference diagnosis and procedure codes with supporting documentation to support transparent output.

Automated medical record intelligence
Medical records are extracted, structured, and summarized to support faster, higher-quality audits. Automated calculations and guided validation help reduce manual effort and reviewer fatigue.

Configurable, transparent  workflows
Health plans retain control through fully configurable workflows and transparent outputs, helping build trust in the review process. 

With Cohere Validate, health plans can shift from vendor dependence and opaque operations to more transparent, in-house, complex claims processing that improves accuracy, efficiency, provider relationships, and profit margins.

Our solution has been shown to deliver:

• 30%-87%  increase in auditor efficiency (vs. traditional operations)
• Up to 100% improvement in hit rates
• 8-9X ROI 

Complex claims aren’t getting simpler—but the way health plans manage them can. Learn how Cohere Health can help your health plan modernize complex claims processing, gain transparency, and move operations in-house. Schedule a demo to see Cohere Validate in action.