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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 documents on this page are for the CCO 2.0 contracts effective October 1, 2019, for coverage effective January 1, 2020, regardless of specific contract year, unless the year is specifically indicated.

 View CCO contract announcements

Financial Reports

Other Reports

2.0 Annual CAC Demographic Report Evaluation Criteria
2.0 Annual CAC Demographic Report Template
2022 CCO Member Handbook Evaluation Criteria
2022 Member Handbook Submission and Review Guidelines
2022 NEMT Rider Guide Evaluation Criteria
2022 NEMT Rider Guide Submission and Review Guidelines
Affiliated Medicare Advantage Plan Report
Attestation Form for Previously Approved Documents 12-2020
Behavioral Health P&D Evaluation Criteria, 02-2021
CANS Data Request Worksheet
Care Coordination Report Template, 02-2021
CCO LTSS Memorandum of Understanding Template FY2020-24
CCO Specific Guidance Overview - Annual LTSS MOU & Reporting
CCO-LTSS Memorandum of Understanding Guidance, CY2020-24
CCO-LTSS MOU Guidance on Sharing Information 12-2020
Claim Count Verification Acknowledgment and Action Form, 10-1-2014
CMS DUR Survey FFY 2020 - FINAL
CMS DUR Survey Guidance
Community Health Assessment and Community and Community Health Improvement Plan - Official Notice
Community Health Assessment and Community Health Improvement Plan Evaluation and Assessment
Community Health Improvement Plan Progress Report Guidance
Community Health Improvement Plan Progress Report Questionnaire
Comprehensive Behavioral Health Plan Evaluation Criteria, 04-2021
Comprehensive Behavioral Health Plan Guidance, 04-2021
Data Certification and Validation Report Form, 10-1-2014
DSN Evaluation Protocol, 05-2021
DSN Provider Capacity Report Template and Instructions, 06-2021
DSN Provider Narrative Template and Instructions, 05-2021
DSN Taxonomy Crosswalk, 06-2021
Enrollment Reconciliation - Discrepancies Found Report, 05-2021
Enrollment Reconciliation - Discrepancy Reporting Guide, June 2021
Enrollment Reconciliation Certification - Discrepancies Found, 05-2021
Enrollment Reconciliation Certification - No Discrepancies Found, 05-2021
FWA Audit Report Template for CY 2021, 03-2021
FWA Deliverables Review Template CY 2021
FWA Program Integrity Glossary of Terms, 03-2020
FWA Referrals and Investigations Report Template for CY 2021, 03-2021
Grievance and Appeal Policy Review
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 Evaluation Tool, 12-2020
Health Equity Plan Guidance 03-2020
Health Equity Plan Section 3 FAQs, 12-2020
Health Equity Plan Submission Template and Instructions, 05-2021
Health Equity Plan Training and Education Reporting Template, 05-2021
Health-Related Services Policy Evaluation Criteria, 12-2020
Hep C DAA CY 2020 Case Management Data Template - Final
Hep C DAA Risk Corridor - Final Definition of Adequate Case Management
Hepatitis C Direct-Acting Antivirals
HIT Roadmap Guidance and Template
IIBHT Progress Report #2, 03-2021
Intensive Care Coordination P&P Evaluation Criteria, 02-2021
Language Access Quarterly Report Instructions 03-2020
Language Self-Assessment - Reference Copy, 12-2020
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
MCE Signature Authorization Form, 05-2021
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Mental Health Parity Analysis Attestation Form, 04-2021
Mental Health Parity Analysis Protocol, 04-2021
Minimum Standards for DUR Programs, effective 10-2019
Minimum Standards for DUR Programs, effective 7-2021
NEMT P&P Evaluation Criteria, 02-2021
NEMT Reporting Template - Technical Specifications, 12-2020
NEMT Reporting Template, 12-2020
NEMT Rider Guide Evaluation Criteria, 03-2020
PBM Pay for Performance Template Instructions, 03-2021
PBM Pay for Performance Template, 03-2021
PCPCH Reporting - Reference Copy, 12-2020
Personal Injury Liens (PIL) Reporting Guidance, 12-2020
PIL Monthly Reporting Template
PIL Reporting Instructions
Preferred Drug List Template
Redaction Log 05-2020
SOC Policy Evaluation Criteria, 05-2021
Subcontractor and Delegated Work Report Attestation, 12-2020
Subcontractor and Delegated Work Report Template, 12-2020
System of Care Statewide Steering Committee Quarterly Report Template, 03-2020
Third-Party Liability (TPL) Notification and Reporting Guidance, 12-2020
THW Integration and Utilization Report for CYs 2020 & 2021
Traditional Health Worker Deliverables Guidance and Evaluation Criteria, 12-2020
Wraparound Policy and Procedure Evaluation Criteria

Annual Behavioral Health Report Documents

Behavioral Health Report Measurement Template, 04-2021
Language Codes
Race and Ethnicity Codes

Contract Templates



CCO Metrics

To learn more and find Quality Pool Reference Instructions, measure specifications and other guidance documents, please visit OHA's CCO Metrics page.

Transformation Center Documents

SHARE Initiative

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

Transformation and Quality Strategy (TQS) 

To learn more, please visit OHA's TQS page.

Value-Based Payments

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


Referenced in the CCO contracts:

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