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DCO Contract Forms

Overview

The dental care organization (DCO) contracts require DCOs to submit various reports. Templates, related forms and documents for these reports are listed here.

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.

Financial Reports

Other Reports

  
  
DCO-Attestation-Form-Approved-Documents-CY2022.docxAttestation Form for Previously Approved Documents, CY 2022 05-2022
DCO-Claim-Count-Verification-Acknowledgment-Action-Form.docClaim Count Verification Acknowledgment and Action Form, 10-1-2014
DCO-Data-Certification-Validation-Report-Form.docData Certification and Validation Report Form, 10-1-2014
DCO-Member-Transition-Closeout-Plan-063022.docxDCO Member Transition and Close-Out Plan, 6-2022
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
OR2022_DSN-Evaluation-Protocol.pdfDSN Evaluation Protocol and Template Instructions, CY 2022
OR2022_DCO_DSN-Narrative-Evaluation-Tool-Template.docxDSN Narrative Evaluation Tool and Reporting Template, CY 2022
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
FWA-Audit-Report-0122.xlsxFWA Audit Report Template for CY 2022, 01-2022
DCO-FWA-Deliverables-Review-CY2021.docxFWA Deliverables Review Template CY 2021
DCO-FWA-Deliverables-Review-CY2022.docxFWA Deliverables Review Template CY 2022
Program-Integrity-Glossary-0122.pdfFWA Program Integrity Glossary of Terms, 01-2022
FWA-Referrals-Investigations-Report-0321.xlsxFWA Referrals and Investigations Report Template for CY 2021, 03-2021
FWA-Referrals-Investigations-Report-0122.xlsxFWA Referrals and Investigations Report Template for CY 2022, 01-2022
DCO-Grievance-System-Report.docxGrievance System Report
DCO-Grievance-System-Reporting-Instructions.docxGrievance System Reporting Instructions
DCO-Health-Equity-Assessment-Template-2022.docxHealth Equity Assessment Template, 07-2022
DCO-Language-Access-Quarterly-Report-Instructions.xlsxLanguage Access Quarterly Report Instructions 03-2020
Language Access Taglines_OHP Medicaid CCO Letters_15 languages.docxLanguage Access Taglines_OHP Medicaid CCO Letters_15 languages
DCO-Language-Self-Assessment-Template120921.pdfLanguage Self-Assessment Template, 12-2021
MCE Annual Letter Checklist.pdfMCE Annual Letter Checklist
MCE Material Reviews - Submission guide.pdfMCE Material Reviews - Submission guide
MCE Nondiscrimination Statement Checklist.pdfMCE Nondiscrimination Statement Checklist
MCE-Signature-Authorization-Form0521.pdfMCE Signature Authorization Form, 05-2021 (PDF)
MCE-Signature-Authorization-Form.docMCE Signature Authorization Form, 05-2021 (Word)
MCE Welcome Letter_ID Card Checklist.pdfMCE Welcome Letter_ID Card Checklist
Model-Depository-Agreement-for-DCOs.docxModel Depository Agreement for DCOs
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Contract Template

2022