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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

  
  
2018 Exhibit L Financial Reporting Supplemental SE.xlsx2018 Exhibit L Financial Reporting Supplemental SE
2018 Exhibit L Financial Reporting Template.XLSX2018 Exhibit L Financial Reporting Template
2018 MLR Instructions.pdf2018 MLR Instructions
2018 MLR Rebate Template.xlsx2018 MLR Rebate Template
2019 Exhibit L Financial Reporting Supplemental SE.xlsx2019 Exhibit L Financial Reporting Supplemental SE
2019 Exhibit L Financial Reporting Template for CCOs.xlsx2019 Exhibit L Financial Reporting Template for CCOs
2019 Exhibit L Financial Reporting Template for MHO DCOs.xlsx2019 Exhibit L Financial Reporting Template for MHO DCOs
2019 MLR Instructions.pdf2019 MLR Instructions
2019 MLR Rebate Template.xlsx2019 MLR Rebate Template
Exhibit L - General Guidelines for CCO HRS Spending.pdfExhibit L - General Guidelines for CCO HRS Spending

 

Other Reports

 
  
  
2018 DUR Survey.pdf2018 DUR Survey
2019 DSN Provider Capacity and Narrative Report Template.xlsx2019 DSN Provider Capacity and Narrative Report Template
2019 Grievance and Appeals Log - Version 3.1.zip2019 Grievance and Appeals Log - Version 3.1
2019 Grievance System Report.docx2019 Grievance System Report
2019 Grievance System Reporting Instructions.docx2019 Grievance System Reporting Instructions
Affiliated Medicare Advantage Plan Report, 10-1-2014.docAffiliated Medicare Advantage Plan Report, 10-1-2014
Attestation of Revision and Submission of Contractually Required Reporting, 10-1-2014.docAttestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
CANS Data Request Worksheet.xlsxCANS Data Request Worksheet
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
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
FWA Assessment Reporting Template.docxFWA Assessment Reporting Template
Hep C DAA CY18 CCO Case Management Data Template Final.xlsxHep C DAA CY18 CCO Case Management Data Template Final
Hep C DAA CY19 CCO Case Management Data Template Final.xlsxHep C DAA CY19 CCO Case Management Data Template Final
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
Minimum Standards for SUPPORT Act Compliance.pdfMinimum Standards for SUPPORT Act Compliance
OHA attestation form for Applied Behavior Analysis CY18.docxOHA attestation form for Applied Behavior Analysis CY18
OHA attestation form for Applied Behavior Analysis CY19.docxOHA attestation form for Applied Behavior Analysis CY19
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
 

Resource Documents - Referenced in the CCO Contract

 

Transformation and Quality Strategy Documents

To learn more, please visit OHA's Transformation and Quality Strategy page.

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