AOI 6 -Autonomous Coding and Denials Mgmt.pdf

Area of Interest #06

Autonomous Coding & Denials Management Services

DoD Healthcare Management System Modernization (DHMSM) Program Management Office

(PMO)

The DHMSM PMO is interested in awarding prototype other transaction agreement(s) for prototype projects under the authority of 10 U.S.C. 4022 for Area of Interest (AOI) #06, Autonomous Coding & Denials Management Services. This AOI #06 leverages the competitive process under Commercial Solutions Opening (CSO) HT0038-25-S-C001.

**Vendors are required to submit in accordance with submission instructions and requirements identified at AOI #06 only.**

AOI #06 Problem Statement

The Government seeks a solution to the Problem Statements listed below:

a. Autonomous Coding Services The Government seeks an autonomous coding capability that utilizes modern, human-like, computational processes to assign medical billing codes from clinical documentation without human intervention and has an auditing capability for the results. Traditional medical coding processes rely heavily on human coders to manually review patient charts and assign appropriate International Classification of Diseases, 10th Revision (ICD-10) codes, Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes, because traditional computational processes have been poor at this type of unstructured pattern recognition. This process is time-consuming, prone to errors, and susceptible to human resource shortages and turnover. The Government is seeking solution(s) to improve overall operational efficiency, coding accuracy, and cost-effectiveness of outpatient and inpatient medical clinics.

b. Automated Appeals & Denials Management Services

The Government currently maintains significantly backlogged aged accounts receivable across multiple systems, creating risk to accurate GAAP-compliant financial reporting and limiting the timely recovery of funds denied by Other Health Insurance payers. Existing manual appeals and denial processes are labor-intensive, inefficient, and unable to resolve multi-year aged receivables at scale. The Government requires a phased, automated solution that improves first-pass claim success, accelerates documentation release, and enhances appeals and denials management to increase recoupment and reduce aged accounts receivable. When the Military Health System (MHS) bills third-party providers, the process of filing claims and appealing denials is closely related to the medical coding processes above. The Government would highly value an integrated automated appeals and denials management solution that generates, and potentially submits, appeals to third-party payers, without a human in the loop. The Government believes this would reduce future claim denials, allow it to assess payer performance through scorecards or key performance indicators, and provide an auditing capability to determine financial impact when coding adjustments are made to the encounter. In total, the Government needs to enable faster and higher recoupment of funds upon initial claim submission and for those inappropriately denied by third-party payers.

Because the vast majority of data necessary to run the coding process is generated by the MHS GENESIS Electronic Healthcare Record (EHR) system, technical integration with the EHR is essential. This means:

1) Ensure bi-directional interoperability with MHS GENESIS using modern interfaces (e.g., HL7 FHIR APIs, HL7 v2.x, and other integration pathways); 2) The solution must meet and maintain DoW Cybersecurity authorization, in accordance with the Risk Management Framework; and 3) Cloud Service Providers (CSPs) will be required to obtain FedRAMP authorization at the high level, IL5/IL6 cloud compliance and CMMC 2.0 certification.

Given the urgent need and the number of existing commercial solutions, the Government will only consider existing Autonomous Coding capability. The Government’s preference is for an existing commercially available Automated Appeals and Denials Management solution, but the Government may consider solutions that require additional development for the Automated Appeals and Denials Management capability. Proposed existing commercial solutions must meet and maintain all required DoW cybersecurity authorizations and the Government will focus on those solutions that can partially integrate in 3 months or less (for pilot) and fully integrate in 12 months or less. DHA intends to award the initial prototype other transaction agreement(s) prior to or on March 31, 2026.

Following a successful prototype, a follow-on production agreement and/or contract may be awarded.

Background

The DHMSM PMO is responsible for leading the effort to modernize healthcare delivery across the MHS.

The DHMSM PMO’s core mission is to deliver an integrated, interoperable health information technology solution that enables the MHS to provide high-quality, cost-effective care to service members, veterans, and their families. This is achieved through the deployment and management of a comprehensive EHR, and associated technologies designed to improve patient care, enhance operational efficiency, and support data-driven decision-making throughout the MHS enterprise.

The DHMSM PMO awarded a contract to Leidos in 2015 for development and deployment of the DoW EHR. To that end, Leidos teamed with Oracle and a number of other commercial vendors to create MHS GENESIS. Today, the DoW EHR is an Oracle Cerner Millenium product that supports the availability of longitudinal health records for more than 9.6 million DoW beneficiaries and has been deployed to over 137 parent hospitals and clinics with a user base of more than 190,000 Defense Health Agency (DHA) personnel.

Instructions for the White Paper

Create a cover page that identifies AOI #06 Autonomous Coding & Denials Management, the solicitation number, the name(s) of the company(ies), website(s), point(s) of contact, and contact information (email address, phone number and mailing address). If a link to the video demonstration (see below) is being provided, please highlight this on the cover page. Responses should clearly indicate whether the company is collaborating with any other organizations to deliver the proposed solution.

The white paper should describe the proposed solution in response to the AOI #06 Autonomous Coding & Denials Management Services Problem Statement. The white paper should not exceed 10 pages in length (5 pages per solution). The cover page is not included in these suggested page limits. If a submission is on behalf of a group of companies, the white paper should address the contribution of each company to the approach. Please be specific in the description of the proposed solution and, where specific software or the approach has been successfully leveraged, provide real-world examples.

Diagrams or figures to depict the proposed solution are encouraged and companies may provide links to public websites with such information. Please do not include elaborate brochures and do NOT include resumes. All submissions shall be unclassified.

While companies are not limited in how they choose to structure their white paper, the Government recommends that they clearly address the following areas in the white paper:

• Autonomous Coding Capability. Describe the capability to include covered medical services, care environments (e.g., inpatient, outpatient, ancillary, etc.), ability to code institutional and professional encounters per care environment, percentage of encounters successfully coded and placed in a final coded state (projected at start and at 3, 6, 9, and 12-month intervals), code selection and assignment accuracy, how accuracy is measured, impact on denial rates and appeal success rates, and examples of time and cost savings achieved through automation. Methods used to measure accuracy, process and user interface for validating, editing and auditing coding results that should include an audit and Clinical Documentation Improvement (CDI) trail for each code assigned per encounter.

• Automated Appeals and Denials Management Capability. Describe how the proposed solution leverages modern, human-like, computational processes to automate the generation and submission of appeals to third-party payers, including the workflow, decision logic, and supporting data sources. Explain how the solution proactively reduces future denials by optimizing coding accuracy, tuning autonomous coding functionality, and/or implementing configurable enterprise-level business rules. Additionally, describe how the solution measures and reports payer performance through dashboards, scorecards, or defined key performance indicators, and outline any built-in auditing capabilities that quantify the financial impact of denials, appeals, and recovered revenue. Include information on reporting outputs, traceability, and how insights support leadership decision-making and audit readiness. If the Automated Appeals and Denials Management capability is in the process of maturing, please include a product development roadmap that details planned future capabilities and a release schedule.

• DoW EHR Data Required to Generate the Coding. Describe how long the company’s solution requires data to be retained to generate the coding, and whether the data retention time can be adjusted to suit the Government’s requirements.

• Advanced Documentation, Automation, and Decision Support. Describe the solutions support capabilities that utilize modern, human-like, computational processes. The response should address the approach to mitigating potential bias within these processes to ensure fairness in clinical decision support. Furthermore, describe the plan for ongoing monitoring and evaluation of system performance to identify and correct any errors or biases.

• EHR Architecture Experience. Describe any experience integrating your solution with the Oracle Cerner Millenium product architecture. Leidos is the current system integrator for MHS GENESIS. The Government anticipates the successful offeror will collaborate with Leidos to integrate the solution into MHS GENESIS.

Given the short time frame to award and the focus on solutions that can partially integrate in 3 months or less (for pilot) and fully integrate in 12 months or less, the Government will focus on those solutions that realistically can satisfy applicable regulatory, security and cybersecurity requirements. To this end, please also address in the white paper:

• How the proposed solution complies with DoWI 8510.01, Risk Management Framework (RMF) for DoW IT and complies with annual Federal Information Security Modernization Act (FISMA) security control testing.

• Whether the solution has obtained or when it is anticipated to obtain FedRAMP authorization at the high level, IL5/IL6.

• The contractor shall obtain and maintain access to the Supplier Performance Risk System (SPRS) via the PIEE, (available via the internet at https://www.sprs.csd.disa.mil/). If a group of companies is submitting a white paper, or any subcontractor(s) are contemplated, provide the status of the current assessment posted in SPRS for each.

• The status of CMMC certification for the company (or companies if a group) and any subcontractor(s) that will be managing CUI.

• Ability to comply with the incident management requirements of Chairman of the Joint Chiefs of Staff Manual (CJCSM) 6510.01B, “Cyber I6ncident Handling Program”.

• Compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

• Ability to encrypt data at rest and in transit.

• Ability to support Common Access Card/Personal Identify Verification (CAC/PIV) authentication.

• Address whether the source code is held in the United States and whether other than United States citizens access, maintain or upgrade the software.

• Ability to accept the terms of the DHA BAA (available online at https://health.mil/Reference-

Center/Policies/2022/01/06/HIPAA-Compliant-Business-Associate-Agreement)

Include an Addendum 1 that identifies whether each company listed on the cover page is a non-traditional defense contractor as defined in 10 U.S.C. 3014 or a non-profit research institution. (In short, a non-traditional defense contractor is an entity that has not received a full Cost Accounting Standards covered contract from the Federal Government within a 12-month period prior to the issuance of this solicitation.) This information should not take more than a page to provide and will not be used to determine which solutions are chosen for the next step of the review process.

Include an Addendum 2 with known licensing terms (end-user licensing agreements) for software/technology included in the approach as well as any other terms and conditions (for example, for services) that the submission would rely upon. References to existing Federal Government contracts with appropriate terms that could be used to streamline negotiations are encouraged. There is no page limit for Addendum 2.

If there are any concerns about sharing information in your white paper with Leidos or any of the Government support contractors identified in the CSO, companies must include a restrictive marking on each relevant page identifying such limitations, as well as a paragraph explaining the concern.

Furthermore, to protect business plans and technical information from FOIA disclosure for a period of five years, companies are required to include a legend on the documents identifying them as being submitted on a confidential basis.

Submit the cover page, white paper and addenda as a single document via email to both Government points of contact listed below. If the white paper submission exceeds 25MB or contains links or other information that is unlikely to successfully pass through the Government’s email system, please email both Government points of contact below, no later than March 05, 2026, to arrange access to Bidscale.

https://www.sprs.csd.disa.mil/

Instructions for Video Demonstration Submission

The Government would like to view a demonstration of the Autonomous Coding and if available, Automated Appeals and Denials Management, solution. If available, companies should include a link for each solution to existing demonstration videos (for example, to a website). If the demonstration video exceeds 7 minutes in length, provide the specific start and end times for the preferred 7-minute segment to be reviewed. If a link is available, please highlight that in the cover page of the white paper.

Alternatively, if companies prefer, they may submit one video per solution that is no more than 7 minutes long through Bidscale. Bidscale videos may not exceed 1.5 GB in size. For companies who wish to submit a video instead of a link, please email both Government points of contact below, no later than March 05, 2026, to arrange access to Bidscale.

If there are any concerns sharing your video with Leidos or any of the Government support contractors identified in the CSO, please include a visible watermark or burn in on the video itself and provide a paragraph to the Government points of contact explaining the concern.

Note that, per the text of the CSO, the Government will not pay for costs associated with the preparation of any other materials used to determine whether the company has merit for purposes of an AOI or is awardable for purposes of a prototype other transaction agreement.

The Government intends to review submissions on a rolling basis beginning on March 02, 2026, and ending on March 09, 2026, at 1:00 p.m. Eastern Time. Interested companies are encouraged to meet the due dates set forth herein as the Government has set aside personnel to review submissions based on these dates. The Government is under no obligation to consider submissions made later than the due date.

The Government will review the solutions described in the white papers and plans to invite the companies whose solutions are most likely to be successful in addressing the Government’s problem statement to engage in a question-and-answer session and/or live demonstration. For companies whose approach does not appear to address the Problem Statement, the Video Demonstration will not be viewed. The live demonstration may include use of real datasets (for the Autonomous Coding capability only), with outputs from each solution provided for review and discussion during the allotted question-and-answer session.

Given the compressed time frame, the Government intends to leverage the flexibility of the other transaction authority and reach out to companies as the Government identifies likely successful solutions instead of waiting and notifying all companies at the same time. The Government may customize its next steps based on the perceived concerns and benefits of each individual solution. This means the process may vary. For example, while one company might be asked to participate in a question-and-answer session, another company might be asked to provide a more detailed demonstration. In yet other cases, the Government may proceed directly to negotiations.

For planning purposes, the selected offeror is expected to integrate the software with MHS GENESIS during the prototyping phase and complete a 3-month pilot (no more than 6 months); however, consideration will be given for an exception to full integration of software with MHS GENESIS during the pilot at the Government’s discretion. The Government will share specific information regarding the pilot as well as its definition of a successful prototype prior to the award of the prototype other transaction award milestone for this pilot.

White paper submissions should be emailed to the following individuals:

• Ms. Dominique Brown dominique.u.brown.civ@health.mil

• Ms. Elizabeth Holten elizabeth.l.holten.civ@health.mil mailto:dominique.u.brown.civ@health.mil mailto:elizabeth.l.holten.civ@health.mil