Service Level Agreement (SLA)
A formal commitment between a service provider and client outlining expected performance metrics. SLAs often include PA turnaround times and approval rates.
Site-of-service nudge
A real-time suggestion that encourages use of a more appropriate or cost-effective care setting (e.g., ambulatory surgery center instead of hospital).
Software as a Service (SaaS)
A cloud model delivering ready-to-use software applications over the internet, accessible by users without installation. Unlike PaaS, SaaS provides complete applications, such as provider portals or dashboards.
STARS (Medicare Star Ratings)
CMS’s performance rating system for Medicare Advantage plans based on quality, access, and patient experience. Cohere supports STARS improvement by optimizing care quality and reducing delays.
Turnaround time (TAT)
The time from when a PA request is submitted to when a decision is returned.
Utilization management (UM)
Utilization management (UM) refers to the processes and workflows health plans use to evaluate whether healthcare services are clinically appropriate, evidence-based, and aligned with coverage policies.
These activities help support appropriate care, consistent clinical and operational workflows, and effective medical expense management across the care continuum.
Utilization Per 1,000 (UPK)
A utilization metric indicating how often a service is used per 1,000 members. Useful for tracking trends and outliers.
Value-based care (VBC)
A reimbursement model that rewards quality outcomes instead of volume.