PEO DHMS - CSO, Area of Opportunity (AOI) 6 - Autonomous Coding & Denials Mgmt

Solicitation / RFP / RFQ

This document, Area of Interest (AOI) #06, solicits prototype Other Transaction Agreement(s) for Autonomous Coding & Denials Management Services. The Department of Defense (DoD) Healthcare Management System Modernization (DHMSM) Program Management Office (PMO) is seeking solutions to improve operational efficiency, coding accuracy, and cost-effectiveness in medical coding, and to automate appeals and denials management for healthcare claims. The goal is to enable faster and higher recoupment of funds from third-party payers.

• Autonomous Coding Services: Capability to assign medical billing codes (ICD-10, CPT, HCPCS) from clinical documentation without human intervention, including an auditing capability for results. Requires integration with the MHS GENESIS Electronic Healthcare Record (EHR).

• Automated Appeals & Denials Management Services: Phased, automated solution to improve first-pass claim success, accelerate documentation release, and enhance appeals and denials management to reduce aged accounts receivable. Ideally, the solution would generate and potentially submit appeals to third-party payers.

• The Government intends to award prototype Other Transaction Agreement(s).

• The Government intends to award the initial prototype agreement(s) on or before March 31, 2026.

• A follow-on production agreement and/or contract may be awarded after a successful prototype.

• Vendors must submit a white paper addressing the problem statements.

• White papers should not exceed 10 pages (excluding cover page and addenda).

• Submissions are due via email by March 05, 2026.

• The Government will review submissions on a rolling basis from March 02, 2026, to March 09, 2026.

• Companies may be invited to a question-and-answer session and/or live demonstration.

• Video demonstrations (max 7 minutes) are also an option for submission.

• The solicitation leverages the competitive process under Commercial Solutions Opening (CSO) HT0038-25-S-C001.

• Addendum 1 requires identification of whether each company is a non-traditional defense contractor or a non-profit research institution.

• Solutions must meet and maintain DoD cybersecurity authorizations (Risk Management Framework) and FedRAMP authorization (Medium level, IL4).

• Cloud Service Providers (CSPs) require FedRAMP authorization, IL4 cloud compliance, and CMMC 2.0 certification.

• Integration with MHS GENESIS is essential. Collaboration with Leidos (the current system integrator) is anticipated.

• The Government will not pay for costs associated with proposal preparation.

• Data provided by the Government is restricted and can only be used for this prototype project.

Solicitation / RFP / RFQ

This document outlines Area of Interest (AOI) #06, "Autonomous Coding & Denials Management Services," for prototype Other Transaction Agreement(s) under 10 U.S.C. 4022. The DoD Healthcare Management System Modernization (DHMSM) Program Management Office (PMO) is seeking solutions to address two key problem statements:

1. Autonomous Coding Services: Develop an autonomous capability to assign medical billing codes (ICD-10, CPT, HCPCS) from clinical documentation without human intervention, including an auditing capability for results. This aims to improve operational efficiency, coding accuracy, and cost-effectiveness, overcoming limitations of traditional manual coding processes.
2. Automated Appeals & Denials Management Services: Implement a phased, automated solution to improve first-pass claim success, accelerate documentation release, and enhance appeals and denials management. This is intended to reduce aged accounts receivable, increase recoupment from Other Health Insurance payers, and potentially automate the generation and submission of appeals.

• Solutions must leverage modern, human-like, computational processes.

• Technical integration with the MHS GENESIS Electronic Healthcare Record (EHR) is essential, requiring bi-directional interoperability (HL7 FHIR APIs, HL7 v2.x).

• Solutions must meet and maintain DoD Cybersecurity authorizations (Risk Management Framework).

• Cloud Service Providers (CSPs) must obtain FedRAMP authorization (Medium level, IL4), CMMC 2.0 certification.

• Preference for existing commercial solutions, but development for the appeals/denials capability may be considered.

• Solutions should be capable of partial integration within 3 months (for pilot) and full integration within 12 months.

• The Government intends to award initial prototype Other Transaction Agreement(s) on or before March 31, 2026.

• A follow-on production agreement and/or contract may be awarded after a successful prototype.

• Interested companies must submit a white paper in response to the problem statement.

• Submission deadline: March 09, 2026, 1:00 p.m. Eastern Time.

• Submissions will be reviewed on a rolling basis from March 02, 2026, to March 09, 2026.

• Companies may be invited to a question-and-answer session and/or live demonstration.

• Video demonstrations (max 7 minutes) are requested for the solutions.

• The solicitation leverages the competitive process under Commercial Solutions Opening (CSO) HT0038-25-S-C001.

• Addendum 1 requires identification of whether companies are non-traditional defense contractors or non-profit research institutions.

• The Government will not pay for costs associated with preparing submissions.

• Offerors must address specific areas in their white paper, including coding capability, appeals/denials management, EHR data requirements, documentation/decision support, and EHR architecture experience (specifically with Oracle Cerner Millenium).

• Cybersecurity, FedRAMP, CMMC, HIPAA, and data encryption requirements must be addressed.

• Addendum 2 should include licensing terms and conditions.

• White paper submissions should be emailed to Ms. Dominique Brown and Ms. Elizabeth Holten.

Other / Unclassified

This document, titled "Government Rider," outlines specific terms and conditions that are non-negotiable for an "other transaction" related to this solicitation. It addresses various legal and contractual aspects, including:

• Order of Precedence: Defines the hierarchy for resolving inconsistencies between this rider, prototype agreements, statements of work, and other attachments.
• Breach: Specifies that liability for breach or claims against the U.S. Government will be determined under the Federal Tort Claims Act or other governing federal authority.
• Modification, Suspension, and Termination: Prohibits unilateral termination by the vendor.
• Governing Law: States that the "Other Transaction" will be governed by U.S. federal law, with no provisions for binding arbitration or equitable remedies inconsistent with federal law.
• Audits: Requires prior notice and consent for access to Government networks.
• Control of Defense: Clarifies that legal representation for the Government is reserved for the U.S. Department of Justice.
• No Endorsement: Prohibits vendors from implying Government endorsement of their products or services without prior approval.
• Payment Terms: States that terms conflicting with Federal Appropriations Law, the Anti-deficiency Act, or the Bona-fide Need Rule are unenforceable. Payments are to be made through Wide Area Work Flow.
• Late Fee Interest Payments: Governed by 31 U.S.C. §3902 et seq.
• Terms Incorporated by Reference: States that terms incorporated by reference (including website links) are unenforceable unless fully attached to the award.
• Automatic Third Party Terms: Unenforceable unless made by bilateral modification.
• Automatic Renewal Terms: Prohibits automatic renewal; any renewal requires modification and approval.
• OPSEC: Mandates compliance with Operational Security requirements.
• Indemnification: The Government will not indemnify any entity.
• Comptroller General Access: Required for prototype OTs exceeding $5 million.
• Authorized Users; Worldwide Use: Defines authorized users for software, including the Defense Health Agency and MHS GENESIS partners, for worldwide use, subject to regulations.

This document is critical for bidders as it establishes fundamental, non-negotiable legal and contractual terms that will govern any award resulting from this solicitation. Bidders must understand these conditions, particularly regarding order of precedence, governing law, payment terms, and restrictions on vendor actions (like endorsements or automatic renewals), to assess the full scope of contractual obligations and risks.

Solicitation / RFP / RFQ

This document is an Area of Interest (AOI) #06, "Autonomous Coding & Denials Management Services," issued by the DoD Healthcare Management System Modernization (DHMSM) Program Management Office (PMO). The government is seeking prototype other transaction agreement(s) for solutions that address two key problem statements: 1) Autonomous Coding Services, and 2) Automated Appeals & Denials Management Services. The goal is to improve operational efficiency, coding accuracy, and cost-effectiveness in medical billing and to accelerate the recovery of funds denied by third-party payers.

• Autonomous Coding: Solutions must utilize modern, human-like, computational processes to assign medical billing codes (ICD-10, CPT, HCPCS) from clinical documentation with high accuracy and an auditing capability. Traditional manual coding is time-consuming and prone to errors.

• Automated Appeals & Denials Management: Solutions should automate the process of filing appeals to third-party payers, improve first-pass claim success, accelerate documentation release, and enhance the management of aged accounts receivable. The aim is to reduce future claim denials and increase recoupment.

• Technical Integration: Solutions must ensure bi-directional interoperability with the MHS GENESIS EHR system using modern interfaces (e.g., HL7 FHIR, HL7 v2.x).

• Security & Compliance: Solutions must meet and maintain DoD Cybersecurity authorizations (Risk Management Framework), FedRAMP authorization (high level, IL5/IL6), CMMC 2.0 certification, and HIPAA compliance.

• Existing Capabilities: The government prefers existing commercially available solutions, particularly for Automated Appeals and Denials Management. Solutions must be capable of partial integration within 3 months and full integration within 12 months.

• The agreement will be a prototype other transaction agreement.

• The government intends to award the initial prototype agreement on or before March 31, 2026.

• A follow-on production agreement and/or contract may be awarded after a successful prototype.

• Interested companies must submit a white paper addressing the proposed solution.

• Submissions are due by March 05, 2026.

• Review of submissions will occur on a rolling basis from March 02, 2026, to March 09, 2026.

• Companies may be invited for question-and-answer sessions and/or live demonstrations.

• The government will focus on solutions that can realistically meet regulatory, security, and cybersecurity requirements.

• The document mentions "non-traditional defense contractor" and "non-profit research institution" in relation to an addendum, but no specific set-aside is mentioned for this AOI.

• Companies are encouraged to provide video demonstrations of their solutions.

• The government will not pay for costs associated with preparing submissions or demonstrations.

• Offerors are encouraged to collaborate with Leidos, the current MHS GENESIS system integrator, for integration.

• Specific instructions are provided for white paper content, including sections on Autonomous Coding Capability, Automated Appeals and Denials Management Capability, EHR Data Requirements, Advanced Documentation/Automation/Decision Support, and EHR Architecture Experience.