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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 report templates on this page are effective January 1, 2020.

Financial Reports

  
2020 Exhibit L Financial Reporting Supplemental SE
2020 Exhibit L Financial Reporting Template for CCOs
2020 MLR Instructions
2020 MLR Rebate Template
Form A – Statement Regarding the Acquisition of Control of or Manage with a CCO
Form B - Insurance Holding Company System Annual Registration Statement
Form C - Summary of Changes to Registration Statement
Form D - Prior Notice of a Transaction
Form F - Enterprise Risk Report
Model Depository Agreement for CCOs
Model Depository Agreement for Sub-Capitated Counterparty

Other Reports

  
Affiliated Medicare Advantage Plan Report, 10-1-2014
Attestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
CANS Data Request Worksheet
CCO Language Self Assessment Template 01-2020
Claim Count Verification Acknowledgment and Action Form, 10-1-2014
Data Certification and Validation Report Form, 10-1-2014
Enrollment Reconciliation Certification - Discrepancies Found, 10-1-2014
Enrollment Reconciliation Certification – No Discrepancies, 10-1-2014
Grievance and Appeals Log - Version 3.2
Grievance System Report
Grievance System Reporting Instructions
Hepatitis C DAA Risk Corridor - Final Definition of Adequate Case Management
Hospital Adequacy Report, 10-1-2014
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
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Minimum Standards for SUPPORT Act Compliance
Pharmacy Expense Report - Proprietary Exemption Request, 10-1-2014
Pharmacy Expense Report, 10-1-2014
Physician Incentive Plan Disclosure Form, 10-1-2014
Signature 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.

Value-Based Payment (VBP) Documents for CCO 2.0 Contract

Learn more about the VBP Roadmap and Technical Guide.

  
VBP CDA and PCPCH Data Template 9-25-19
VBP Measures Reporting Form 9-27-19
VBP Metrics Exception Request 9-27-19
VBP Targets and PCPCH Data Template 9-25-19

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