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

DRAFT — Statement of Objectives: Autonomous Coding & Appeals and Denials Management 1 STATEMENT OF OBJECTIVES for AUTONOMOUS CODING & AUTOMATED APPEALS AND DENIALS MANAGEMENT 1. BACKGROUND Military Treatment Facilities (MTFs) across the Defense Health Agency (DHA) enterprise experience high encounter coding volume, increased coding errors, a growing volume of denied claims, and limited ability to predict which claims will be denied before submission. To manage these challenges, DHA requires an artificial intelligence/machine learning (AI/ML)-enabled solution capable of adapting and improving dynamically based on data patterns in order to autonomously code clinical encounters; prioritize and resolve denied claims; and prevent denials before claim submission. 2. KEY DEFINITIONS 2.1. Final coded. An encounter is “final coded” when the solution assigns a complete code set and applicable modifiers sufficient for claim submission and releases the encounter without human intervention, with an audit trail traceable to the source documentation. This is the same unit of measure used for invoicing under Section 7.4; the terms “autonomously coded” and “successfully encoded” carry the same meaning throughout this SOO. 2.2. Coverage. Autonomous coding coverage shall be expressed against total in-scope encounter volume. Any encounter volume the solution excludes from autonomous coding shall be reported together with the basis for exclusion and the resulting exclusion rate. 2.3. Production. The live, operational technical environment utilized for actual day-to-day data operations integrated with MHS GENESIS. This definition refers strictly to the hosting and execution environment for processing live military health data and is distinct from, and should not be confused with, "follow-on production" acquisition pathways, contracts, or transactions as defined under 10 U.S.C. § 4022. 3. APPROACH & OBJECTIVES 3.1. FUNCTIONAL OBJECTIVES • Autonomous Coding (AC): Provide an AI/ML capability to automatically assign medical billing codes without human intervention. Solutions should process roughly 143K encounters daily (4.35M monthly) with no later than 24-hour turnaround, adhering to current coding guidelines with full transparent auditability (“explainability”). • Appeals and Denials Management (ADM): Use AI/ML to automate the generation of appeals, reduce future claim denials, assess payer performance, and provide auditing for financial impacts. -- 1 of 9 -- DRAFT — Statement of Objectives: Autonomous Coding & Appeals and Denials Management 2 3.2. SHARED OBJECTIVES (Joint Vendor Solution Requirements) If the Government does not select a single vendor to provide both solutions, the selected Vendors must work collaboratively, as needed, to integrate their solutions in order to meet the following requirements: 1. Comprehensive Reporting Dashboards: Vendors will provide unified reporting dashboards that consolidate data and analytics from both vendors’ systems, presenting a cohesive view of the complete solution performance and outcomes. 2. Interdependent Algorithm Learning: The vendors will implement interdependent machine learning algorithms that operate across both the Autonomous Coding (AC) and Appeals and Denials Management (ADM) systems. The algorithms must be designed to share learning insights and optimize performance across both vendors' platforms in a coordinated manner. 3. Secure Data Exchange and Integration: o Phase 1 (Initial): Vendors will establish secure, compliant file transfer protocols between their respective systems to enable data exchange while maintaining HIPAA compliance and DoD security requirements. o Phase 2 (Ultimate): Vendors will collaboratively develop and implement integration capabilities with MHS GENESIS that:  Enable seamless data flow between both vendor solutions and MHS GENESIS  Preserve MHS GENESIS core functionality without modification  Utilize approved MHS GENESIS APIs, interfaces, or integration points as designated by the Government  Maintain all security, privacy, and interoperability standards required by the Defense Health Agency and Department of War. The vendors will designate technical leads responsible for coordination and shall provide joint integration plans, testing protocols, and documentation demonstrating successful interoperability between their systems upon implementation of Capability 1 and 2 as outlined below. 4. Execution Phases & Deliverables The project will be executed via a two-capability, milestone-driven structure. AC and ADM may or may not start in parallel with pending award (s) but will follow the same milestone process. Advancement to the live production environment (Milestone 4) is strictly gated by the successful progressive completion of cybersecurity, onboarding, and performance metrics in the pre-production environment (Milestones 1, 2, and 3). 4.1. CAPABILITY 1: AUTONOMOUS CODING • Milestone 1: Onboarding & Cybersecurity o Objective: Establish secure baseline for DOD data handling. -- 2 of 9 -- DRAFT — Statement of Objectives: Autonomous Coding & Appeals and Denials Management 3 o Criteria: All vendor personnel assigned to this effort shall be credentialed (CAC). Risk Management Framework (RMF) artifacts approved for an Interim Authority to Test (IATT). • Milestone 2: Testing in Pre-Production Environment o Successfully Autonomously Code Outpatient/Clinic encounters utilizing an established set of MHS GENESIS workflows, user roles, and approved test data that will be provided by the Government. Success at this milestone requires autonomous coding of ≥ [60] % of the approved test volume at ≥ 95% code-level accuracy, reported by encounter category, within the 24-hour turnaround objective. o Recommended priority order (Outpatient/Clinic encounters) for testing in Pre-Prod:  Family Medicine, Internal Medicine, and Flight Medicine  Behavioral Health  Laboratory  Emergency Medicine  Radiology to include its …