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CCO Contract Forms


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 for the CCO 2.0 contracts effective October 1, 2019.

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Financial Reports

2020 Exhibit L Financial Reporting DCO Template
2020 Exhibit L Financial Reporting Supplemental SE
2020 Exhibit L Financial Reporting Template for CCOs
2020 MLR Instructions
2020 MLR Rebate Template
2021 Exhibit L Financial Reporting Template
Form A - Statement Regarding the Acquisition or Control of or Manage with a CCO
Form B: Insurance Holding Company System Annual Registration Statement: Exhibit 2 – OAR 836-027-0010 (rev. 9-1-15)
Form C: Summary of Changes to Registration Statement: Exhibit 3 – OAR 836-027-0012 (rev. 9-1-15)
Form D: Prior Notice of a Transaction: Exhibit 4 – OAR 836-027-0160 (rev. 9-1-15)
OAR 836-027-0140: Exhibit 6, Form F: Enterprise Risk Report
Model Depository Agreement for CCOs
Model Depository Agreement for Sub-Capitated Counterparty

Other Reports

2020 Mental Health Parity Analysis
Affiliated Medicare Advantage Plan Report – Updated template coming soon
Attestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
CANS Data Request Worksheet
CCO LTSS Memorandum of Understanding Template FY2020-24
CCO Specific Guidance Overview - Annual LTSS MOU & Reporting
CCO to LTSS Memorandum of Understanding Guidance FY2020-24
Claim Count Verification Acknowledgment and Action Form, 10-1-2014
Data Certification and Validation Report Form, 10-1-2014
DSN Evaluation Protocol 2020
DSN Provider Capacity and Annual Narrative Report Template 2020
DSN Provider Capacity Report Review FAQ
Enrollment Reconciliation Certification - Discrepancies Found, 10-1-2014
Enrollment Reconciliation Certification – No Discrepancies, 10-1-2014
Exhibit B Part 8 Section 17 - PIL Monthly Reporting Template
Exhibit B Part 8 Section 17 - PIL Reporting Instructions
FINAL - 2019 CMS DUR Survey
Fraud Waste and Abuse Deliverables Attestation for previously submittted documents 03-2020
Fraud Waste and Abuse Deliverables Review Template 03-2020
FWA Annual Audit and Investigations Report Template 12-2019
FWA Quarterly Report Template 12-2019
Grievance and Appeals Log - Version 3.5
Grievance System Report
Grievance System Reporting Instructions
Health Equity Infrastructure FAQ 03-2020
Health Equity Plan - Community Engagement Alternate Process Guidance Document
Health Equity Plan Guidance 03-2020
Hep C DAA CY 2020 Case Management Data Template - Final
Hep C DAA Risk Corridor - Final Definition of Adequate Case Management
Language Access Quarterly Report Instructions 03-2020
Language Self Assessment Template 01-2020
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
Mental Health Parity Analysis Protocol
Mental Health Parity Required Documentation Template
Minimum Standards for SUPPORT Act Compliance
PBM Contract Pay for Performance Reporting Instructions
PBM Contract Pay for Performance Reporting Template
Pharmacy Expense Report - Proprietary Exemption Request, 10-1-2014
Pharmacy Expense Report, 10-1-2014
Preferred Drug List Template
Program Integrity Glossary of Terms 03-2020
Quarterly Report to the System of Care Statewide Steering Committee Template 03-2020
Redaction Log 05-2020
Signature Authorization Form, 10-1-2014
Subcontractor and Delegated Work Report Attestation
Subcontractor and Delegated Work Report Template

Resource Documents - Referenced in the CCO Contract

Annual Behavioral Health Report Documents

Annual Report Guidance
Prior Authorization SUD Residential Measure Template
Prior Authorization Youth MH Residential Template
Wraparound Measure Template
Language Codes
Race and Ethnicity Codes

SHARE Initiative Documents

To learn more and find reporting templates, please visit OHA's SHARE Initiative page..

Transformation and Quality Strategy Documents

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

Value-Based Payment (VBP) Documents

To learn more, please visit OHA's Value-Based Payment page.

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