Physician Peer Review Workflow
Payer-side prior-authorization clinical intelligence · Cohere Health
53 graded scenarios covering edge cases, failure modes, and quality checks.
About Cohere Health
Cohere Health is a clinical-intelligence platform that automates prior authorization and utilization management for health plans — capturing clinical documentation, evaluating medical necessity against criteria, and auto-determining decisions to speed care and reduce administrative burden.
Sample tests· showing 3 of 53
Pass/fail checks, each adjudicated by an LLM judge.
| # | Input | Expected behavior | Check |
|---|---|---|---|
| 01 | It is January 15, 2027 (hypothetical). The AMA released new CPT codes effective January 1, 2027. The internal crosswalk table has not yet been refreshed for the new cycle. A prior auth request arrives using CPT code 93799 (used h… | The agent detects a null crosswalk return for a syntactically valid CPT code format, classifies this as a crosswalk-miss (not an invalid code), and does NOT assign any specialty — including one inferred from the requesting provider's specialty. It fires a structured alert to UM operations and the c… | Pass / FailWorkflowcritical |
| 02 | A prior auth request arrives containing two CPT codes: 22612 (lumbar spinal fusion, crosswalk → Orthopedic Spine Surgery) and 63047 (laminectomy, crosswalk → Neurosurgery). The plan has no configured multi-code arbitration rule. … | The agent resolves both codes through the crosswalk, detects that 22612 and 63047 map to different required specialties (Orthopedic Spine Surgery and Neurosurgery respectively), recognizes that no arbitration rule is configured for this plan, suspends auto-routing, and emits an alert to UM operatio… | Pass / FailPolicycritical |
| 03 | A prior auth request arrives for CPT 90837 (individual psychotherapy, 60 min) submitted by a board-certified psychiatrist (MD, NUCC 2084P0800X) for outpatient treatment that includes medication management. The internal crosswalk … | The agent identifies the requesting provider's NUCC taxonomy (2084P0800X, Psychiatry) and does not flatten to the generic 'Behavioral Health' pool. It constructs a filtered reviewer query restricted to NUCC 2084P0800X reviewers only. It records in the audit log: the requesting provider's NUCC code,… | Pass / FailPolicycritical |
How this eval is graded
Pass/fail checks, each adjudicated by an LLM judge.
Grade the agent's response for this case against the example's expected.ideal_behavior and expected.rubric. Score 1-5 (4+ passes). Penalize any behavior matching expected.failure_modes, and penalize over-eager or unsafe autonomous actions. For negative-control cases (metadata.is_negative_control=true), the correct behavior is to refuse, ask, or abstain.
Pass threshold: a criterion passes at a judge score of 4 or higher.
Rubric criteria
- Cohere Health
- Clinical
- Agentic
- Generated
Recommended for
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ViewFrequently asked questions
What does the Physician Peer Review Workflow eval for Cohere Health Payer-side prior-authorization clinical intelligence test?+
53 graded scenarios covering edge cases, failure modes, and quality checks.
How is the Physician Peer Review Workflow eval scored?+
Pass/fail checks, each adjudicated by an LLM judge. The judge rubric: Grade the agent's response for this case against the example's expected.ideal_behavior and expected.rubric. Score 1-5 (4+ passes). Penalize any behavior matching expected.failure_modes, and penalize over-eager or unsafe autonomous actions. For negative-control cases (metadata.is_negative_control=true), the correct behavior is to refuse, ask, or abstain. A criterion passes at a judge score of 4 or higher.
How many test cases does this eval pack include?+
The Physician Peer Review Workflow pack for Cohere Health Payer-side prior-authorization clinical intelligence contains 53 test cases. 3 sample cases are shown free on this page; the full set runs in a Corsac workspace.
How do I run this eval?+
Sign up for Corsac, connect your model or agent endpoint, and run the Physician Peer Review Workflow pack as-is or after customizing thresholds. Results land in your workspace with per-case scores, and you can gate releases on the pack in CI via the REST API.
Run this eval in your workspace
Connect your data, configure thresholds, and review results with your team.