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DCO Contract Forms


This page contains templates and related forms for dental care organizations (DCOs) to use when submitting their contract deliverables to the Oregon Health Authority (OHA).

Fraud, Waste and Abuse (FWA) policies and procedures:

Exhibit B, Part 9, subsection 17 (Obligations to Report FWA: Policies and Procedures) b. and  c. of the DCO contracts require use of a reporting template. DCOs will be using the CCO template for their submissions.

Also refer to the CMS Medicaid Program Integrity website for more information about how to implement FWA policies and procedures at the practice level.

2020-MLR-Instructions-DCO.pdf2020 MLR Instructions for DCOs
2020-MLR-Template-DCO.xlsx2020 MLR Rebate Template for DCOs
2021-Exhibit-L-Financial-Reporting-DCO-Template.xlsx2021 Exhibit L Financial Reporting DCO Template
2022 DCO Member Handbook Evaluation Criteria.xlsx2022 DCO Member Handbook Evaluation Criteria
2022 DCO Member Handbook Submission and Review Guidelines.pdf2022 DCO Member Handbook Submission and Review Guidelines
DCO-DSN-Provider-Narrative-Report-Instructions-2021.pdfDSN Annual Provider Narrative Instructions, 05-2021
DCO-DSN-Provider-Narrative-Template-2021.xlsxDSN Annual Provider Narrative Template, 05-2021
MCE-DSN-Evaluation Protocol-2021.pdfDSN Evaluation Protocol, 05-2021
DCO-DSN-Quarterly-Provider-Capacity-Report-2021.xlsxDSN Provider Capacity Report Template and Instructions, 06-2021
MCE-DSN-Taxonomy-Crosswalk-2021.xlsxDSN Taxonomy Crosswalk, 06-2021
Discrepancies-Found-Report.xlsxEnrollment Reconciliation - Discrepancies Found Report, 05-2021
Discrepancies-Found-Form.docxEnrollment Reconciliation Certification - Discrepancies Found, 05-2021
No-Discrepancies-Found-Form.docxEnrollment Reconciliation Certification - No Discrepancies Found, 05-2021
DCO-FWA-Deliverables-Review-CY2021.docxFWA Deliverables Review Template CY 2021
FWA-Referrals-Investigations-Report-0321.xlsxFWA Referrals and Investigations Report Template for CY 2021, 03-2021
Grievance-Appeal-Policy-Review.xlsxGrievance and Appeal Policy Review
DCO-Grievance-System-Report.docxGrievance System Report
DCO-Grievance-System-Reporting-Instructions.docxGrievance System Reporting Instructions
DCO-Language-Access-Quarterly-Report-Instructions.xlsxLanguage Access Quarterly Report Instructions 03-2020
MCE Material Reviews - Submission guide.pdfMCE Material Reviews - Submission guide
MCE Nondiscrimination Notice Checklist.pdfMCE Nondiscrimination Notice Checklist
MCE-Signature-Authorization-Form.docMCE Signature Authorization Form, 05-2021
MCE Welcome Letter_ID Card Checklist.pdfMCE Welcome Letter_ID Card Checklist
Model-Depository-Agreement-for-DCOs.docxModel Depository Agreement for DCOs
DCO-Subcontractor-Delegated-Work-Report-Attestation.docxSubcontractor and Delegated Work Report Attestation, 12-2020
DCO-Subcontractor-Delegated-Work-Report.xlsxSubcontractor and Delegated Work Report Template, 01-2021

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