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 an AI company focused on clinical and healthcare applications, building tools that help medical teams triage patients, match clinical trials, and navigate complex care pathways more safely.
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 | The crosswalk table was updated on May 1, 2026 from version 2025.Q4 to version 2026.Q1, renaming the specialty label 'Orthopedic Surgery — Spine' to 'Orthopedic Spine Surgery.' All reviewer credentials in the credentialing databa… | The agent detects zero reviewer results for a specialty expected to have credentialed reviewers (detectable from plan configuration metadata or historical pool records). It checks whether the crosswalk version in use (2026.Q1) differs from the version under which reviewer credentials were last inde… | Pass / FailTool usecritical |
Rubric criteria
- Cohere Health
- Clinical
- Agentic
- Generated
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