SAM #HT0038RFSACADM

DHA Seeks AI/ML Solutions for Autonomous Medical Coding and Automated Appeals Management

This opportunity seeks advanced AI/ML solutions to modernize healthcare revenue cycle operations for the Defense Health Agency (DHA) and the Defense Healthcare Management Systems Modernization (DHMSM) Program Management Office. - Government Buyer: - Defense Health Agency (DHA) - Defense Healthcare Management Systems Modernization (DHMSM) Program Management Office (PMO) - OEMs and Vendors: - No specific OEMs or vendors are named; open to all qualified providers of AI/ML healthcare solutions - Products/Services Requested: - Autonomous Coding (AC) Solution: - AI/ML-enabled system to assign medical billing codes (ICD-10, CPT, HCPCS) from clinical documentation without human intervention - Must achieve 95% code-level accuracy and process approximately 143,000 daily encounters - Requires auditability, explainability, and integration with MHS GENESIS - Turnaround time under 24 hours per encounter - Automated Appeals & Denials Management (ADM) Solution: - AI/ML-enabled, phased solution to automate appeals generation and submission - Reduce claim denials by at least 20% and aged accounts receivable days - Improve first-pass claim success and accelerate documentation release - Provide full audit trail and require human approval for financial actions - Integration with MHS GENESIS and secure data exchange required - Unique/Notable Requirements: - Solutions must be fully auditable and explainable - Must integrate with the MHS GENESIS electronic health record system - Security compliance and collaborative vendor integration are mandatory - Measurable performance improvements (e.g., reduction in denials, improved recoupment) - Phased onboarding, testing, and production milestones with defined accuracy and performance targets

Description

Request for Solutions (RFS): Autonomous Coding (AC) and Automated Appeals & Denials Management (ADM)

Opportunity Overview

The Defense Healthcare Management Systems Modernization (DHMSM) Program Management Office (PMO), in conjunction with the Defense Healthcare Management Systems Program Executive Office (DHMS PEO) is seeking innovative, Artificial Intelligence and Machine Learning (AI/ML) enabled solutions to enhance healthcare delivery and strengthen financial recovery operations across the Military Health System (MHS).

Pursuant to 10 U.S.C. § 4022, the Government intends to award one or more prototype Other Transaction Agreements (OTAs) through this competitive Request for Solutions (RFS) process.

Under this RFS, the DHMSM PMO is seeking solutions for two distinct capability areas. Industry partners may submit a solution for either capability individually or for both capabilities:

Capability 1: Autonomous Coding (AC) – A solution that uses advanced, human-like AI/ML computational processes to assign medical billing codes from clinical documentation without human intervention, while maintaining full auditability and explainability. Capability 2: Automated Appeals & Denials Management (ADM) – A phased, automated solution designed to address backlogged aged Accounts Receivable (A/R), improve first-pass claim success, accelerate documentation release, and automate the generation and submission of appeals to third-party payers.

Important Instructions for Interested Parties

Interested parties are strongly encouraged to review the attached documents in their entirety for complete details regarding this opportunity, including submission requirements and other specific instructions.

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