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CCO Contract Forms

Overview

The coordinated care organization (CCO) contracts require CCOs to submit various reports. Templates, related forms and documents for these reports are listed here.

Financial Reports

  
  
2017 Exhibit L Financial Reporting Template.xlsx2017 Exhibit L Financial Reporting Template
2017 Medical Loss Ratio Rebate Instructions.pdf2017 Medical Loss Ratio Rebate Instructions
2017 Medical Loss Ratio Rebate Template.xlsx2017 Medical Loss Ratio Rebate Template

 

Other Reports

  
  
2017 CCO Contract Deliverables Tool.xlsx2017 CCO Contract Deliverables Tool
2017-CHIP-ProgressReport-Guidance-Template.docx2017-CHIP-ProgressReport-Guidance-Template
Affiliated Medicare Advantage Plan Report, 10-1-2014.docAffiliated Medicare Advantage Plan Report, 10-1-2014
Appendix to Exhibit J - Review Tool for CCO Informational Material.docxAppendix to Exhibit J - Review Tool for CCO Informational Material
Attestation of Revision and Submission of Contractually Required Reporting, 10-1-2014.docAttestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
Claim Count Verification Acknowledgment and Action Form, 10-1-2014.docClaim Count Verification Acknowledgment and Action Form, 10-1-2014
Data Certification and Validation Report Form, 10-1-2014.docData Certification and Validation Report Form, 10-1-2014
DSN Capacity Report 2017.xlsxDSN Capacity Report 2017
Enrollment Reconciliation Certification - Discrepancies Found, 10-1-2014.xlsxEnrollment Reconciliation Certification - Discrepancies Found, 10-1-2014
Enrollment Reconciliation Certification – No Discrepancies, 10-1-2014.docEnrollment Reconciliation Certification – No Discrepancies, 10-1-2014
Grievance Report, 10-1-2015.xlsGrievance Report, 10-1-2015
Hepatitis C DAA Risk Corridor - Final Definition of Adequate Case Management.pdfHepatitis C DAA Risk Corridor - Final Definition of Adequate Case Management
Hospital Adequacy Report, 10-1-2014.docHospital Adequacy Report, 10-1-2014
Measures and Outcomes Tracking System (MOTS), 10-1-2014.docMeasures and Outcomes Tracking System (MOTS), 10-1-2014
Pharmacy Expense Report - Proprietary Exemption Request, 10-1-2014.docPharmacy Expense Report - Proprietary Exemption Request, 10-1-2014
Pharmacy Expense Report, 10-1-2014.docPharmacy Expense Report, 10-1-2014
Physician Incentive Plan Disclosure Form, 10-1-2014.docxPhysician Incentive Plan Disclosure Form, 10-1-2014
Procedure and Request Form - LTPC Determinations, Age 17 and Under - 10-1-2014.docProcedure and Request Form - LTPC Determinations, Age 17 and Under - 10-1-2014
Procedure and Request Form - LTPC Determinations, Age 18-64 - 10-1-2014.docProcedure and Request Form - LTPC Determinations, Age 18-64 - 10-1-2014
Procedure and Request Form - LTPC Determinations, Neuropsychiatric Treatment - 10-1-2014.docProcedure and Request Form - LTPC Determinations, Neuropsychiatric Treatment - 10-1-2014
Signature Authorization Form, 10-1-2014.docSignature Authorization Form, 10-1-2014

  

2015-2017 Transformation Plan Progress Report Templates

  
AllCare-ProgressRpt3Template
CHA-ProgressRpt3Template
CPCCO-ProgressRpt3Template
EOCCO-ProgressRpt3Template
FamilyCare-ProgressRpt3Template
Health Share-ProgressRpt3Template
IHN-ProgressRpt3Template
JCC-ProgressRpt3Template
PrimaryHealth-ProgressRpt3Template
PS-CG-ProgressRpt3Template
PS-CO-ProgressRpt3Template
Trillium-ProgressRpt3Template
Umpqua-ProgressRpt3Template
WOAH-ProgressRpt3Template
WVCH-ProgressRpt3Template
Yamhill-ProgressRpt3Template

Resource Documents - Referenced in the CCO Contract

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