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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 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

  
2020 Exhibit L Financial Reporting Supplemental SE
2020 MLR Instructions
2020 MLR Rebate Template
2020 Exhibit L Financial Reporting Template for CCOs
2021 Exhibit L Financial Reporting Supplemental SE
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

  
Affiliated Medicare Advantage Plan Report
Attestation Form for Previously Approved Documents 12-2020
CANS Data Request Worksheet
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
Community Advisory Council Demographic Report Template, 10-2020
Comprehensive Behavioral Health Progress Report Template, 11-2020
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
FWA Annual Referrals and Investigations Report Template for CY 2020, 12-2020
FWA Audit Report Template for CY 2020, 12-2020
FWA Deliverables Review Template CY 2021
FWA Program Integrity Glossary of Terms, 03-2020
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-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
IIBHT Progress Report 1, 12-2020
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
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Mental Health Parity Analysis Protocol
Mental Health Parity Analysis, 06-2020
Mental Health Parity Required Documentation Template
Minimum Standards for SUPPORT Act Compliance
NEMT Reporting Template - Technical Specifications, 12-2020
NEMT Reporting Template, 12-2020
NEMT Rider Guide Evaluation Criteria, 03-2020
PBM Contract Pay for Performance Reporting Instructions
PBM Contract Pay for Performance Reporting Template
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
Signature Authorization Form, 10-1-2014
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
Traditional Health Worker Deliverables Guidance and Evaluation Criteria, 12-2020

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

Contract Templates

2021

2020

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.

Resources

Referenced in the CCO contracts:

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