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.

For contract year 2024 due dates, please refer to Exhibit D, Attachment 1 of the 2024 contract.
For contract year 2023 due dates, please refer to Exhibit D, Attachment 1 of the 2023 contract.
For due dates and documents for prior contract years, please refer to the CCO Contract Forms archive.

View CCO contract announcements

Financial Reports

Other Reports

URL
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 - 2023
Attestation for PA Determinations for SUD Services - 2024
Behavioral Health Directed Payment FAQ for CY 2023
Behavioral Health Directed Payment Guidance Document for CY 2023
Behavioral Health P&P Evaluation Criteria, 12-2021
CANS Data Request Worksheet
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
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, 05-2021 (PDF)
Delegation Authorization and Signature Form, 05-2021 (Word)
DSN Material Change Notification Form
DSN Narrative Evaluation Q&A, CY 2023
DSN Narrative Evaluation Tool and Reporting Template, CY 2023
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, 12-2023
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
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 2023, 01-2023
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 2023, 01-2023
Grievance and Appeal System Policies and Procedure Review - Guidance for MCEs_2023
Grievance and Appeal System Policies and Procedures Evaluation - 2023
Grievance and Appeal System Reporting FAQ 2023
Grievance and Appeals Log 2023
Grievance System Code Tables 2023
Grievance System Report 2023
Grievance System Reporting Instructions 2023
Health Equity Plan Evaluation Tool, 04-2023
Health Equity Plan Guidance Document, 04-2023
Health Equity Plan Template, 04-2023
Health Equity Plan Training and Education Reporting Template, 05-2021
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
HIT Roadmap Guidance, Evaluation Criteria, and Report Template 2023 – Option A
HIT Roadmap Guidance, Evaluation Criteria, and Report Template 2023 - Option B
HIT Roadmap Guidance, Evaluation Criteria, and Report Template 2023 – Option C
IIBHT Quarterly Report Template, 10-2023
Indian Health Care Program Payments, 01-2023
Intensive Care Coordination Policy & Procedure Evaluation Criteria, 12-2021
Language Access and Interpreter Services Report Instructions, 09/2022
Language Access Self-Assessment Survey (Reference Copy), 12-2022
Language Access Taglines_OHP Medicaid CCO Letters_15 languages
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
Measures and Outcomes Tracking System (MOTS), 10-1-2014
Medicare - Attestation for Automated Crossover Claims, 12-2021
Member Handbook CCO Model Handbook 2024, updated: 08/15/2023
Member Handbook CCO Model Member Handbook Redline Changes List 2024, updated: 08/15/2023
Member Handbook Evaluation Criteria 2024, updated: 08/15/23
Member Handbook Submission and Review Guidelines 2024, updated: 08/15/2023
Member Materials - Annual Letters Evaluation Criteria
Member Materials Submission Guide for the CCO Deliverables Portal
Member Notice Template Evaluation Criteria_2023
Member Notice Template Submission and Review Guidelines 2023
Mental Health Parity Evaluation Data Submission Template 2023
Mental Health Parity Evaluation Protocol 2023
Mental Health Parity Evaluation Treatment Limitation Review Tool 2023
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 Call Intake Script Evaluation Criteria. 2023
NEMT Policies and Procedures Attestation for CY 2024
NEMT Policies and Procedures Evaluation Tool for CY 2022
NEMT Policies and Procedures Evaluation Tool for CY 2023
NEMT Policies and Procedures Evaluation Tool for CY 2024
NEMT Policies and Procedures Guidance for CY 2023
NEMT Policies and Procedures Procedures Guidance for CY 2022
NEMT Reporting Template - Technical Specifications, 12-2020
NEMT Reporting Template, 12-2020
NEMT Rider Guide Evaluation Criteria 2024
NEMT Rider Guide Submission and Review Guidelines 2024
NOABD and Prior Authorization Sample Evaluation Criteria 2023
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 Attestation P&Ps, 12/1/2023
PIL Lien Templates Self-Evaluation Checklist, 11/29/2023
PIL lien templates, 12/1/2023
PIL Monthly Reporting Template
PIL P&P Self-Evaluation Checklist, 11/2023
Preferred Drug List Template
Quality Pool Distribution Plan Template, 05-2023
Redaction Log, 06-2022
SOC P&P Evaluation Criteria, 12-2021
Subcontractor and Delegated Work Report Attestation, 01-2024
Subcontractor and Delegated Work Report, 01-2024
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 Policy & Procedure Evaluation Criteria, 12-2021