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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

  
Exhibit L - General Guidelines for CCO HRS Spending
CCO Model Depository Agreement
2019 MLR Rebate Template
2019 MLR Instructions
2019 Exhibit L Financial Reporting Template for MHO DCOs
2019 Exhibit L Financial Reporting Template for CCOs
2019 Exhibit L Financial Reporting Supplemental SE
2018 MLR Rebate Template
2018 MLR Instructions
2018 Exhibit L Financial Reporting Template
2018 Exhibit L Financial Reporting Supplemental SE

Other Reports

  
2018 DUR Survey
2019 DSN Provider Capacity and Narrative Report Template
2019 Grievance and Appeals Log - Version 3.2
2019 Grievance System Report
2019 Grievance System Reporting Instructions
Affiliated Medicare Advantage Plan Report, 10-1-2014
Attestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
CANS Data Request Worksheet
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
FWA Assessment Reporting Template
Hep C DAA CY18 CCO Case Management Data Template Final
Hep C DAA CY19 CCO Case Management Data Template Final
Hepatitis C DAA Risk Corridor - Final Definition of Adequate Case Management
Hospital Adequacy Report, 10-1-2014
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Minimum Standards for SUPPORT Act Compliance
OHA attestation form for Applied Behavior Analysis CY18
OHA attestation form for Applied Behavior Analysis CY19
Pharmacy Expense Report - Proprietary Exemption Request, 10-1-2014
Pharmacy Expense Report, 10-1-2014
Physician Incentive Plan Disclosure Form, 10-1-2014
Procedure and Request Form - LTPC Determinations, Age 17 and Under - 10-1-2014
Procedure and Request Form - LTPC Determinations, Age 18-64 - 10-1-2014
Procedure and Request Form - LTPC Determinations, Neuropsychiatric Treatment - 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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