Delegated Utilization Management
Different strategies.
Legacy utilization management models weren't built for the speed, transparency, and provider experience health plans need now. Compare approaches and see how clinical intelligence reshapes outcomes across medex, provider experience, and review accuracy.
Cohere in action.
96%
provider digital adoption rate
69
provider NPS score
64%
reduction in plan call volume vs. legacy vendors
45%
savings from withdrawals and nudges, not denials
>50%
fewer overturns vs. prior vendors
Delegated UM
Legacy UM vendors
How decisions are supported
Clinician-trained AI extracts clinical evidence, supporting faster reviewer workflows and real-time approval rates of 50–90%.
Rules-based workflows with limited clinical data extraction. Heavy reliance on clinical assessment questions and manual review.
Role of clinical expertise
A same-specialty, board-certified physician conducts peer-to-peer reviews. AI is never used to deny care.
Peer-to-peer reviews by non-specialty physicians can lower review quality and increase the chance of appeals.
Reviewer workload and efficiency
ML-assisted review extracts clinical data and maps it to guidelines, reducing review time by 40% and error rates by 30%.
Relying on clinical assessment questions, not ML, increases FTE dependency and causes delays from missing information.
Provider experience
96% digital provider adoption, 69 NPS score, 64% reduction in call volume & 40% reduction in provider time spent on authorizations.
Provider portals with manual data entry, fax follow-up, and low NPS scores. High provider call volume driven by process friction.
Source of medical expense savings
Drive savings with efficiency and clinical accuracy. 45% of savings come from provider nudges and withdrawals, not denials. AI is never used to deny care.
Denial-driven approach where savings are eroded by the downstream cost of managing appeals, overturns, and provider abrasion.
Appeals and overturns
More than 50% fewer overturns vs. prior vendors. Technology prevents denials due to missing information before they occur.
Higher appeal rates stemming from denials based on missing or incomplete information.
CMS-0057-F readiness
Production-ready FHIR APIs, including a single API that supports both in-house and delegated UM across a plan's full ecosystem.
Vendor-specific API surfacing without the ability to create a single integration point across a plan's full UM ecosystem.
Business model and incentives
Admin fee pricing model that avoids incentivizing denials and supports MLR attribution as a quality improvement program.
Majority of revenue tied to risk-based contracts, which can create incentives that conflict with payer compliance and provider trust goals.
Why Health Plans Choose Cohere Health
Cohere streamlines the prior authorization process, making it efficient and effective. With our platform, health plans can leverage automation to enhance clinical decision-making.
A provider experience that earns trust
Providers engage with Cohere's digital workflow instead of manual processes, which leads to high digital adoption, a positive NPS score, and reduced call volume for health plans.
Fewer delays. Fewer overturns. Better decisions.
Cohere's clinician-trained AI extracts clinical evidence and maps it to guideline criteria, which reduces errors and improves first-pass accuracy. This helps members get faster access to the right care.
Savings built on accuracy, not denials
By focusing on efficiency and clinical accuracy instead of denial volume, Cohere Health's approach has delivered incremental medical expense savings compared to previously managed programs and meaningful reductions in denials across delegated specialties.
What Others Are Saying
Ready to see what **modern** delegated UM looks like?
Cohere Health helps health plans move away from legacy UM vendors with delegated programs, in-house automation, and hybrid models built for how your organization operates.