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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. 

All documents on this page are for the CCO 2.0 contracts effective October 1, 2019, for coverage effective January 1, 2020, regardless of specific contract year, unless the year is specifically indicated.

 View CCO contract announcements

Financial Reports

Other Reports

  
Affiliated Medicare Advantage Plan Guidance, 09-2022
Affiliated Medicare Advantage Plan Report, 09-2022
Attestation Form for Previously Approved Documents, CY 2023
Behavioral Health P&P Evaluation Criteria, 12-2021
CAC Demographic Report Guidance, Evaluation Criteria & Report Template for CY 2022
CANS Data Request Worksheet
Care Coordination Report Template, 05-2022
CCO Language Self-Assessment
Claim Count Verification Acknowledgment and Action Form, 10-1-2014
CMS DUR Survey FFY 2021 - Fillable PDF
CMS DUR Survey FFY 2021 – INFORMATIONAL COPY
CMS DUR Survey FFY 2021 Guidance
Comprehensive Behavioral Health Plan Evaluation Criteria and Guidance Document Crosswalk, 05-2022
Comprehensive Behavioral Health Plan Progress Report Evaluation Criteria, 04-2022
Comprehensive Behavioral Health Plan Progress Report Evaluation Criteria, 04-2022
Comprehensive Behavioral Health Plan Progress Report Guidance, 04-2022
Data Certification and Validation Report Form, 10-1-2014
DSN Evaluation Protocol and Template Instructions, CY 2022
DSN Narrative Evaluation Tool and Reporting Template, CY 2022
DSN Provider Capacity Feedback and OHA Response to Reporting, CY 2023
DSN Provider Capacity Report Template and Instructions, CY 2023
Enrollment Reconciliation - Discrepancies Found Report, 05-2021
Enrollment Reconciliation - Discrepancy Reporting Guide, June 2021
Enrollment Reconciliation Certification - Discrepancies Found, 05-2021
Enrollment Reconciliation Certification - No Discrepancies Found, 05-2021
EPSDT Guidance, 11-17-2022
Family Connects Oregon Guidance, 10-2021 (Updated 2/24/2022)
FWA Annual Assessment Report - Attestation for Previously Submitted Documents, 11-2022
FWA Audit Report Template for CY 2021, 03-2021
FWA Audit Report Template for CY 2022, 01-2022
FWA Deliverables Review Template, CY 2023
FWA Program Integrity Glossary of Terms, 01-2022
FWA Referrals and Investigations Report Template for CY 2021, 03-2021
FWA Referrals and Investigations Report Template for CY 2022, 01-2022
Grievance and Appeal System Policies and Procedure Review - Guidance for MCEs_2023
Grievance and Appeal System Policies and Procedures Evaluation - 2023
Grievance and Appeals Log 2023
Grievance and Appeals Log, 08-2022
Grievance System Code Tables 2023
Grievance System Report 2023
Grievance System Report, 08-2022
Grievance System Reporting Instructions 2023
Grievance System Reporting Instructions, 08-2022
Health Equity Plan Submission Template and Instructions, 03-2022
Health Equity Plan Training and Education Reporting Template, 03-2022
Hep C DAA Risk Corridor – Final Definition of Adequate Case Management, 2023
Hepatitis C DAA CY2021 Case Management Data Template - Final
HIT Roadmap Guidance, Evaluation Criteria, and Report Template
Intensive Care Coordination Policy & Procedure Evaluation Criteria, 12-2021
Language Access and Interpreter Services Report Instructions, 09/2022
Language Access Taglines_OHP Medicaid CCO Letters_15 languages
Language Self-Assessment - Reference Copy, 12-2020
Language Self-Assessment Template, 12-2021
LTPC Determinations for Ages 17 and Under - Request Form, revised 1-14-2020
LTPC Determinations for Ages 17 and Under - Request Process, revised 12-31-2019
LTPC Determinations for Ages 18-64 - Request Process and Form, revised 10-1-2014
LTPC Determinations for Neuropsychiatric Treatment - Request Process and Form, revised 10-1-2014
LTSS CCO-Specific Guidance: Annual MOU and Reporting, 11-2022
LTSS Memorandum of Understanding Guidance, CY 2020-24
LTSS Memorandum of Understanding Template, CY 2020-24
LTSS MOU Guidance on Sharing Information 12-2020
LTSS MOU Report Template - CY 2022
MCE Annual Letter Checklist
MCE Material Reviews - Health Risk Assessment Checklist
MCE Material Reviews - Submission guide
MCE Nondiscrimination Statement Checklist
MCE Signature Authorization Form, 05-2021 (PDF)
MCE Signature Authorization Form, 05-2021 (Word)
MCE Welcome Letter_ID Card Checklist
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Medicare - Attestation for Automated Crossover Claims, 12-2021
Member Handbook CCO Model Handbook_Final 2023
Member Handbook Evaluation Criteria_Final 2023
Member Handbook Submission and Review Guidelines_Final 2023
Member Notice Template Evaluation Criteria_2023
Member Notice Template Submission and Review Guidelines 2023
Mental Health Parity Analysis Attestation Form, 04-2021
Mental Health Parity Analysis Protocol, 04-2021
Minimum Standards for DUR Programs, effective 10-2019
Minimum Standards for DUR Programs, effective 7-2021
NEMT Call Intake Script Evaluation Criteria. 2023
NEMT Policies and Procedures Evaluation Tool for CY 2022
NEMT Policies and Procedures Evaluation Tool for CY 2023
NEMT Policies and Procedures Guidance for CY 2023
NEMT Policies and Procedures Procedures Guidance for CY 2022
NEMT Reporting Template - Technical Specifications, 12-2020
NEMT Reporting Template, 12-2020
NEMT Rider Guide Submission and Review Guidelines 2023
NEMT Rider Guide_Evaluation Criteria_Final 2023
NOABD and Prior Authorization sample evaluation criteria, 08-2022
PBM Market Check Report Template, 10-2021
PBM Pay for Performance Template Instructions, 03-2021
PBM Pay for Performance Template, 03-2021
PBM Readiness Checklist (PDF)
PBM Readiness Checklist (Word)
PCPCH Reporting - Reference Copy ,12-2021
Personal Injury Liens Policies and Procedures Evaluation Criteria, 11-2022
Personal Injury Liens Requirements - Policy and Procedure Guidance , 11-2022
PIL Monthly Reporting Template
Preferred Drug List Template
Quality Pool Distribution Plan Template, 05-2022
Redaction Log, 06-2022
SOC P&P Evaluation Criteria, 12-2021
Subcontractor and Delegated Work Report Attestation, 01-2023
Subcontractor and Delegated Work Report, 01-2023
System of Care Statewide Steering Committee Quarterly Report Template, 03-2020
Third-Party Liability Notification and Reporting Guidance, 11-2022
Third-Party Liability Recovery P&P Evaluation Criteria, 11-2022
THW Deliverables Guidance and Evaluation Criteria, 08-22
THW Deliverables Instructions and Plan Update Template, 08-2022
THW Integration and Utilization Data Report Template, 08-2022
TPL Reporting Guidance
Wraparound Policy & Procedure Evaluation Criteria, 12-2021

Annual Behavioral Health Report Documents

  
Behavioral Health Report Measurement Template, 07-2022 (corrected 9/28/2022)
Language Codes
Race and Ethnicity Codes

Contract Templates

2023

2022

2021

2020

CCO Metrics

To learn more and find Quality Pool Reference Instructions, measure specifications and other guidance documents, please visit OHA's CCO Metrics page.

Transformation Center Documents

Community Health Assessment (CHA) and Community Health Improvement Plan (CHP)

To learn more, please visit OHA's page for CHA/CHP guidance and training.

Health-Related Services (HRS)

To learn more, please visit OHA's HRS page.

SHARE Initiative

To learn more and find reporting templates, please visit OHA's SHARE Initiative page.

Performance Improvement Projects (PIPs)

To learn more, please visit OHA's Quality Improvement Program page. 

Transformation and Quality Strategy (TQS) 

To learn more, please visit OHA's TQS page.

TQS Template

TQS Guidance

Value-Based Payments

To learn more, please visit OHA's Value-Based Payment page.

Resources

Referenced in the CCO contracts: