Cohere Health **glossary**

A professional organization that develops clinical practice guidelines and quality standards for orthopedic care. Cohere incorporates AAOS guidelines into its musculoskeletal (MSK) prior authorization workflows to ensure evidence-based, high-quality decision-making.

A network of doctors and hospitals that share responsibility for coordinating care and controlling costs for a population.

A facility that provides short-term inpatient care for patients with serious health conditions, typically involving prior authorization for high-cost procedures.

The process of reviewing and determining the appropriate payment amount for healthcare claims based on contract terms, medical necessity, and coding accuracy.

The excessive time and resources spent on non-clinical tasks like prior authorizations. Administrative burden often leads to clinician burnout and inefficiencies in care delivery. Cohere’s automation and AI-powered workflows aim to significantly reduce administrative burden by simplifying PA processes, minimizing manual data entry, and providing clear guidance through nudges and integrated clinical decision support.

An AI-powered notification within the prior authorization workflow that helps providers submit complete and accurate authorization requests. Cohere’s platform leverages nudges to improve provider experience and ensure efficient, evidence-based care authorization.

Enacted in 2010, the ACA is a foundational U.S. healthcare law that expanded insurance coverage, mandated quality improvement, and incentivized value-based care models. The ACA increased the demand for efficient utilization management to balance access and cost control. Cohere’s platform supports ACA goals by enabling transparent, automated prior authorization processes that align with policy-driven care standards.

AI systems capable of purposeful, goal-directed actions across complex workflows. Cohere deploys agentic AI to manage end-to-end prior authorization decisions with minimal human intervention.

Software components that act autonomously or semi-autonomously to execute tasks. In Cohere’s system, agents may extract clinical data, evaluate policy logic, or trigger workflows.

An outpatient facility performing same‑day surgical procedures. Cohere includes site-of-service considerations to guide appropriate use of ASCs over inpatient settings.

A professional medical society that sets clinical guidelines and standards for cardiovascular care. Cohere references ACC guidelines to ensure cardiac-related prior authorizations reflect best practices.

The largest professional association of physicians and medical students in the U.S., responsible for developing clinical coding standards such as CPT® (Current Procedural Terminology). AMA codes are widely used in billing and prior authorization processes.

The file format used to distribute and install Android mobile apps. Relevant for mobile applications supporting provider access to PA tools or EHR features.

Software tools that enable systems to share data. Cohere APIs integrate with health plan and provider systems for seamless, real-time PA processing.

Technology that simulates human reasoning. Cohere applies AI to streamline clinical decision-making and automate prior authorization processes.

A chronological record of all actions taken during the claims review process, essential for compliance and accountability in payment integrity systems.

A payment model where providers receive a single payment for all services related to a treatment or condition over a specific period.

Efforts or solutions to improve the quality, completeness, and accuracy of clinical record documentation.

A FHIR-based standard enabling providers and health plans to exchange clinical documents electronically—key to CMS interoperability mandates.

The federal agency overseeing Medicare and Medicaid. CMS sets regulations and policies affecting utilization management, including PA requirements and interoperability standards. Cohere’s platform is designed to comply with CMS mandates.

An identifier for Medicare-participating providers, used in billing and prior authorization workflows.

A regulation requiring health plans to adopt APIs for PA and data exchange. Cohere’s APIs support compliance with CMS-0057-F.

Standardized codes that are maintained by the AMA to describe procedures for billing and prior authorization.

A FHIR-based API enabling providers to query payer systems to learn which services require PA and what documentation is needed.

A structured, evidence-based clinical pathway designed to guide appropriate treatment decisions.

A measure of how well health services increase the likelihood of desired outcomes.

Formal requests submitted by healthcare providers to insurance companies or government programs (such as Medicare, Medicare Advantage, and Medicaid) for payment of medical services rendered to patients. Claims contain detailed information, including patient demographics, diagnoses, procedures performed, dates of service, and associated medical codes that determine reimbursement amounts.

The automated process of reviewing claims for errors, inconsistencies, and compliance issues before submission or payment.

A standardized, human-readable language developed by HL7 to express clinical logic for quality measures, decision support, and coverage rules. Cohere may use CQL to encode medical policies and guidelines into executable rules for intelligent, automated prior authorization.

Technology that provides healthcare professionals with patient-specific assessments and evidence-based recommendations to enhance decision-making.

The use of data-driven insights derived from clinical documentation, outcomes, and evidence-based guidelines to inform better healthcare decisions. Clinical intelligence powers Cohere’s AI-driven platform, enabling accurate prior authorization decisions, improving care alignment, and supporting predictive analytics across utilization management workflows.

Evidence-based recommendations that guide appropriate care. 

AI that is purpose-built for use in regulated healthcare environments, capable of interpreting clinical data safely, accurately, and in alignment with clinical standards. Clinical-grade AI emphasizes transparency, explainability, and auditability—building trust among physicians, health plans, and regulators by ensuring that automated decisions are consistent with medical policy and subject to human oversight.

The process of verifying that medical codes (ICD-10, CPT, HCPCS) accurately reflect the services provided and diagnoses documented.

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Aligns health plans and providers around evidence-based pathways for high-quality, cost-effective care.

End-to-end outsourced UM solution using AI and clinical expertise to handle all prior authorizations.

A set of APIs and tools that integrate directly into provider workflows for real-time, automated PA.

The Cohere technology platform that unifies all aspects of the authorization process into a single workflow to reduce fragmentation and delays.

Ongoing surveillance of healthcare transactions to ensure adherence to regulatory requirements and contractual obligations.

A classification system that categorizes into groups based on their diagnoses, procedures, age, sex, and discharge status to determine fixed payment amounts. DRG validation plays a crucial role in payment integrity by ensuring accurate assignment of these classifications, preventing overpayments and underpayments to hospitals, and contributing to overall healthcare cost control through both pre-pay and post-pay review processes.

The systematic review of inpatient claims to verify that the assigned DRG accurately reflects the patient's condition and care provided, often involving clinical chart review and medical record analysis.

A FHIR API that automates the collection of clinical documentation for prior authorization using payer-specific templates.

The systematic examination of healthcare data using computational tools to uncover patterns, trends, and anomalies. Data analytics supports utilization management by identifying potential payment errors, fraud, or inappropriate care, enabling targeted interventions. Cohere applies advanced analytics to optimize prior authorization and payment integrity.

Third-party vendors that are authorized to manage utilization review on behalf of a health plan. Delegated vendors help scale UM operations but require oversight to maintain quality and compliance. Cohere’s platform supports integration and governance of delegated vendor activities.

Efforts to reduce or reverse prior authorization denials. Effective denials management improves provider satisfaction and patient access to care. Cohere provides tools to prevent denials through AI-powered nudges and comprehensive review.

The degree to which users embrace digital tools and platforms. High digital adoption leads to more efficient workflows, reduced errors, and better data capture.

Reusable medical equipment that often requires health plan approval prior to patient delivery.

The connection of external tools or platforms with a provider’s electronic health record (EHR) system to enable real-time data exchange. Cohere offers EHR integration for embedded prior authorization and clinical decision support.

The ability of EHR systems to share and use information across organizations. Interoperability is essential for care coordination and meeting CMS mandates. Cohere’s platform leverages standards like FHIR to enable interoperability.

The day-to-day clinical tasks and data entry processes performed within the EHR. Cohere designs prior authorization tools that fit naturally into EHR workflows to minimize disruption and improve adoption.

Automated validation rules that screen claims for errors, inconsistencies, or potential fraud before processing. Edit checks enhance data quality and reduce downstream denials or audits. Cohere incorporates edit checks into its workflows to ensure accuracy.

Non-emergent procedures planned in advance. Often subject to prior authorization to ensure appropriateness and manage cost. Elective surgeries often require prior authorization to verify medical necessity and appropriate timing.

The digital chart system used by providers. Often a component of broader EHR platforms.

A single authorization covering an entire episode of care rather than individual services—streamlining care and reducing friction.

Clinical decision-making based on current best evidence, clinical expertise, and patient preferences. Incorporating evidence-based care within prior authorization helps ensure appropriate, high-quality treatments

A standard for exchanging healthcare data electronically. FHIR enables real-time data sharing critical for prior authorization automation. Cohere’s APIs utilize FHIR to connect health plans and providers.

Programs designed to identify and prevent improper payments resulting from intentional deception, inefficient practices, or misuse of resources.

Advanced analytical techniques and algorithms designed to identify potentially fraudulent billing patterns and suspicious claims.

A policy allowing providers with a history of high-quality, guideline-adherent care to bypass prior authorization on select services.

The automatic, real-time approval of PA requests based on complete and guideline-aligned clinical data, enabled by Cohere’s AI.

Smart workflows that assist providers in submitting clinically complete PA requests with minimal friction. Guided PA reduces errors, denials, and administrative burden. Cohere’s platform embeds guided PA directly into provider systems.

A widely used set of standardized performance measures developed by NCQA to evaluate health plan quality, outcomes, and patient experience. HEDIS scores are used by CMS and commercial health plans to assess and compare plan performance. Cohere’s platform supports improved HEDIS outcomes by enabling timely, evidence-based care through efficient PA.

An industry-recognized certification for healthcare data security and compliance. Achieving HITRUST certification demonstrates compliance with regulations such as HIPAA. Cohere maintains HITRUST certification to guarantee secure data handling.

Systems that allow for the sharing of health data across organizations.

The principle of ensuring fair access to healthcare regardless of socioeconomic or demographic status. Addressing health equity requires removing barriers in care access and administrative processes. Cohere’s solutions promote equity by streamlining PA and improving transparency.

Documentation outlining how to implement technical standards like FHIR APIs (e.g., PAS, CRD, DTR) for prior authorization automation. Cohere’s platform adheres to relevant IGs for seamless integration.

Care delivered when a patient is formally admitted to a hospital. IP services often require more rigorous review and tracking.

An advanced, AI-driven approach to prior authorization that uses real-time clinical data, evidence-based guidelines, and automation to streamline approvals. Intelligent PA reduces administrative burden, accelerates care access, and improves decision consistency. Cohere’s platform operationalizes intelligent prior authorization by embedding it directly into provider workflows and aligning it with health plan policy.

The ability of different health systems and software to share and use information. A critical component of CMS-mandated modernization. Cohere leverages standards-based interoperability to connect health plans and providers.

A type of AI trained on vast text data, capable of understanding and generating human-like language. Used in clinical summarization and document extraction.

A health plan's insurance segment, e.g., Commercial, Medicare Advantage, or Medicaid, each with specific utilization requirements.

Medicare policies created by regional contractors to define service coverage where no national policy exists. Cohere’s logic engine incorporates LCDs where applicable.

A branch of AI where algorithms learn from data to make predictions.

Traditional PA methods involving phone calls, faxes, or manual form submission. Manual PA is time-consuming, error-prone, and increases administrative burden. Cohere automates and digitizes PA workflows to replace manual methods.

The total spending on healthcare services by individuals, plans, or systems.

The process of evaluating whether a healthcare service, procedure, or treatment is appropriate, evidence-based, and essential for a patient’s condition. It ensures the service meets coverage criteria set by medical policy or clinical guidelines.

The process of converting health plan medical policies into machine-readable, rule-based logic to support real-time, AI-driven authorization decisions.

A private alternative to traditional Medicare with added benefits. MA plans are heavily regulated and central to many CMS initiatives affecting UM.

A high-cost clinical category involving bones, joints, and muscles. Cohere integrates MSK-specific guidelines and workflows to optimize PA for orthopedic and related services.

Medicare’s official national policy statements that specify coverage criteria for services. These policies are encoded in Cohere’s automated authorization logic.

A 10-digit number used to identify healthcare providers in claims and PA processes.

An AI capability that allows it to read, interpret, and extract meaning from unstructured text like clinical notes. Cohere uses NLP to surface cognitive findings and support medical necessity determination.

A measure of user satisfaction and loyalty, based on how likely someone is to recommend a product or service. Used to evaluate provider and member experience with Cohere’s platform.

An in-workflow suggestion or alert that guides providers toward higher-quality, evidence-based care during the PA process. Nudges reduce errors and incomplete submissions, and improve adherence to guidelines.

Medical services provided without hospital admission. OP procedures often represent high volumes of PA activity and are key targets for automation.

A payer-defined list of services that require pre-approval before delivery.

A FHIR API that supports electronic PA submission, tracking, and determination. Required under CMS-0057-F for compliance.

A financial metric reflecting average costs per enrollee each month. Used by health plans to evaluate program performance.

A cloud model providing the underlying environment—like infrastructure and tools—to build, deploy, and manage applications. Unlike SaaS, PaaS offers the foundation for creating software rather than delivering finished apps.

The strain on doctors caused by administrative tasks like prior authorizations.

Emotional exhaustion and stress experienced by physicians, often due to administrative overload. Cohere contributes by reducing PA friction and enhancing physician enablement.

The practice of equipping physicians with tools and information that make it easier to deliver effective, compliant care. Cohere’s platform focuses on physician enablement by embedding clinical decision support and simplifying prior authorization tasks.

The extent to which users consistently use a new platform.

Using historical and real-time data to anticipate future outcomes.

A process requiring provider approval before certain services are rendered to ensure clinical appropriateness and health plan coverage. Cohere transforms PA through AI-driven automation, interoperability, and embedded clinical guidance.

The rate at which healthcare providers embrace and use a new tool or workflow.

The strain placed on providers by administrative tasks, particularly prior authorizations and documentation demands. Cohere reduces provider burden through automation and embedded support.

Strategies and tools that simplify a provider’s experience and improve performance.

The cumulative impact of interactions and workflows on providers.

The ongoing practice of adhering to laws, regulations, and standards (e.g., HIPAA, CMS rules). Cohere’s platform is designed to ensure regulatory compliance through audit logs, data governance, and secure interoperability.