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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

Other Reports

  
2024 Insolvency Plan Guidance
2024 Insolvency Plan Template
Affiliated Medicare Advantage Plan Guidance, 08-2023
Affiliated Medicare Advantage Plan Report, 08-2023
Allowed Amount Guidance Document, 01-2023
Attestation for PA Determinations for SUD Services - 2024
Behavioral Health Directed Payment FAQ for CY 2024
Behavioral Health Directed Payment Guidance Document for CY 2024
Behavioral Health Report Measurement Template, 07-2022 (corrected 9/28/2022)
Care Coordination Report Template, 06-2023
CBHP Evaluation Criteria, 10-2023
CBHP Implementation Guide, 10-2023
CBHP Reporting Template, 10-2023
CCO Deliverables Portal Training with account setup information
CCO Portal Frequently Asked Questions
CCO Welcome Packet and Annual Letter Evaluation Criteria 2025
Checklist for Medicaid Member Materials
Claim Count Verification Acknowledgment and Action Form, 10-1-2014
CMS DUR Survey FFY 2022 – INFORMATIONAL COPY
Data Certification and Validation Report Form, 10-1-2014
Delegation Authorization and Signature Form, 12/29/2023
DSN Evaluation Protocol, CY 2024
DSN Evaluation Reporting Template, CY 2024
DSN Material Change Notification Form
DSN Narrative Evaluation TA FAQ, CY 2024
DSN Provider Capacity Feedback and OHA Response to Reporting, CY 2023
DSN Provider Capacity Report Instructions, CY 2024
DSN Provider Capacity Report Template and Instructions, CY 2024
DSN Provider Specialty Matrix, April 2024
DSN Time and Distance Exception Request Process and Form, CY 2024
DSN Time and Distance Exception Request Process FAQ, 06/14/2024
Enrollment Reconciliation - Discrepancy Reporting Guide, June 2021
Family Connects Oregon Guidance, 06-2023
Fraud Waste and Abuse (FWA) Annual Guidance Document 2024
Fraud Waste and Abuse (FWA) Annual Template 2024
FWA Annual Assessment Report - Attestation for Previously Submitted Documents, 11-2022
FWA Audit Report Template for CY 2024, 02-2024
FWA Deliverables Review Template, CY 2023 (HSAG)
FWA Deliverables Review Template, CY 2023 (OPI)
FWA Fraud Waste and Abuse FAQ 2023
FWA Program Integrity Glossary of Terms, 01-2022
FWA Referrals and Investigations Report Template for CY 2024, 02-2024
Grievance and Appeal System P&Ps Attestation, 2-29-2024
Grievance and Appeal System Policies and Procedures Evaluation Criteria, 2024
Grievance and Appeal System Reporting FAQ 2023
Grievance and Appeals Log 2023
Grievance System Code Tables 2024
Grievance System Report 2023
Grievance System Reporting Instructions 2023
Health Equity Plan Evaluation Tool, 04-2024
Health Equity Plan Guidance Document, 04-2024
Health Equity Plan Report Template, 04-2024
Health Equity Plan Training and Education Reporting Template, 04-2024
Health IT Roadmap 2024 Guidance Evaluation Criteria and Report Template_Final
Health Related Social Needs Guidance Document, 06/2024
Health Related Social Needs Readiness Review Template 2024
Health-Related Services and 2022-2027 OHP Waiver Updates, May 2024
Health-Related Services Exhibit L Financial Reporting Template Guidance, May 2024
Health-Related Services Policy Evaluation Criteria, 06-2023
Hep C DAA CY 2023 Case Management Data Template
Hep C DAA Risk Corridor – Final Definition of Adequate Case Management, 2023
HRS Policy and Procedure Evaluation Criteria 2024
IIBHT Quarterly Report Template, 10-2023
Indian Health Care Provider Reimbursement Guidance for 2024, 1/9/2024
Language Access and Interpreter Services Report Instructions, 09/2022
Language Access and Interpreter Services Report Instructions, 12/19/2023
Language Access Self-Assessment Survey (Reference Copy), 12-2022
Language Self-Assessment - Reference Copy, 12-2020
Language Self-Assessment Template, 12-2021
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
LTSS CCO-Specific Guidance: Annual MOU and Reporting, 11-2022
LTSS Memorandum of Understanding Guidance, CY 2020-24
LTSS Memorandum of Understanding Template, CY 2020-24
LTSS MOU Guidance on Sharing Information 12-2020
LTSS MOU Report Template - CY 2022
LTSS MOU Report Template - CY 2024
MCIS Guidance for CCOs, 12/2023
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Member Handbook - CCO Model Handbook - 2025 Redline version
Member Handbook - CCO Model Member Handbook - 2025 No Markup version
Member Handbook Evaluation Criteria 2025
Member Handbook Insert for OHP Bridge starting July 1 2024
Member Handbook Submission and Review Guidelines 2025
Member Materials Submission Guide for the CCO Deliverables Portal
Member Notice Template Self-Evaluation Checklist for CY 2024
Member Notice Templates Attestation, 02-28-2024
Mental Health Parity Data Submission Template 2024
Mental Health Parity Evaluation Data Submission Template 2023
Mental Health Parity Evaluation Protocol 2023
Mental Health Parity Evaluation Treatment Limitation Review Tool 2023
Mental Health Parity Protocol 2024
Mental Health Parity Treatment Limitation Attestation Tool 2024
Minimum Standards for DUR Programs, effective 10-2019
Minimum Standards for DUR Programs, effective 7-2021
NEMT Call Center Script Attestation for CY 2024
NEMT Call Center Script Self-Evaluation Checklist for CY 2024
NEMT Policies and Procedures Attestation for CY 2024
NEMT Policies and Procedures Self-Evaluation Checklist for CY 2024
NEMT Quarterly QA Reporting Template -Technical Specifications, 03/29/2024
NEMT Quarterly QA Reporting Template, 03/29/2024
NEMT Rider Guide Evaluation Criteria 2025
NEMT Rider Guide Submission and Review Guidelines, 2025
NOABD and Prior Authorization sample evaluation criteria 2024
OHA attestation form for Applied Behavior Analysis CY19
PBM Market Check Report Template, 03-2023
PBM Pay for Performance Template Instructions, 03-2021
PBM Pay for Performance Template, 03-2021
PBM Readiness Checklist (PDF)
PBM Readiness Checklist (Word)
PCPCH Reporting - Reference Copy and Evaluation Criteria, 10-2023
PIL Lien Templates Attestation, 12/1/2023
PIL Lien Templates Self-Evaluation Checklist for CY 2024, 11/29/2023
PIL Monthly Reporting Template
PIL P&Ps Attestation, 12/1/2023
PIL P&Ps Self-Evaluation Checklist for CY 2024, 11/29/2023
Preferred Drug List Template
Quality Pool Distribution Plan Evaluation Criteria, 2024
Quality Pool Distribution Plan Template, 2024
Redaction Log, 06-2022
Risk Stratification Evaluation Critiera, CY 2024
SOC P&P Self-Evaluation Checklist for CY 2024, 12/18/2023
SOC P&Ps Attestation for CY 2024, 12/15/2023
Statewide Performance Improvement Project (PIP) validation tool, 2024
Subcontractor and Delegated Work Report Attestation, 01-2024
Subcontractor and Delegated Work Report, 01-2024
Subcontractor Compliance Review Tool, 2024
Subcontractor Performance Report Evaluation Criteria with Guidance, 2024
System of Care Statewide Steering Committee Report Template, 03-2020
THW Deliverables Guidance and Evaluation Criteria, 10-2023
THW Deliverables Instructions and Plan Update Template, 10-2023
THW Integration and Utilization Data Report Template, 10-2023
TPL Reporting Guidance
TPLR P&P Evaluation Criteria, 12/1/2023
TPLR Reporting Guidance, 12/1/2023
Wraparound P&Ps Attestation for CY 2024, 12/15/2023
Wraparound P&Ps Self-Evaluation Checklist for CY 2024, 12/18/2023



CCO 2.0 Contract Templates

2024

2023

2022

2021

2020

CCO Portal Login

Resources

Transformation Center guidance and templates

Community Health Assessment (CHA) and Community Health Improvement Plan (CHP)

To learn more, please visit OHA's page for CHA/CHP guidance and training.

Community Advisory Council (CAC)

SHARE Initiative

Guidance Reporting templates

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

Transformation and Quality Strategy (TQS) 

2024 template

2024 guidance

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

Value-Based Payments

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

CCO Deliverables Portal
Login to the CCO Portal


Account and System Requests

  • Use the Account Requests form to request a new account or remove an existing account. Accounts are limited to CCO staff.

Training and Documentation

Member Notice templates

​Member Materials

For general guidance, please see the Material Submissions and Reviews page.

NOABD, NOAR templates

Please see templates below for Notice of Adverse Benefit Determination and Notice of Appeal Resolution. These templates were updated in January 2024.


Notice Workgroup

In Lieu of Services (ILOS)

​In lieu of services (ILOS) are services determined by the state to be medically appropriate and cost-effective substitutes for covered services or settings under the State Medicaid Plan. ILOS must meet requirements outlined in 42 CFR 438.3(e)(2). Please see guidance and resources below:

For more information about ILOS, visit the ILOS page.


Health Related Social Needs (HRSN)

​The 2022-2027 1115 Medicaid Demonstration Waiver includes ground-breaking authority to provide health related social needs (HRSN) services as a covered Oregon Health Plan (OHP) benefit to eligible Open Card/Fee-For-Service (FFS) and coordinated care organization (CCO) Members, including individuals who are Members through the Healthier Oregon Program. The approved HRSN Services include housing, nutrition, climate-related supports, and outreach and engagement services.

Learn more and see updates on the HRSN page.