DCO Contract Forms

Overview

This page contains templates and related forms for dental care organizations to use when submitting their contract deliverables to OHA, effective January 1, 2020.

Please ensure DCO member material meets applicable requirements in OHA's Member Communication Requirements document. This is a guide for preparing Member Handbooks and other member materials.
Also refer to OHA's March 2020 memo for deliverable due dates for contract year 2020: Changes to DCO deliverable due dates due to COVID-19 response

Fraud, Waste and Abuse (FWA) policies and procedures:

Exhibit B, Part 9, subsection 17 (Obligations to Report FWA: Policies and Procedures) b. and c. of the DCO contracts require use of a reporting template. DCOs will be using the CCO template for their submissions.

Also refer to the CMS Medicaid Program Integrity website for more information about how to implement FWA policies and procedures at the practice level.

Type	URL
	2020 Exhibit L Financial Reporting DCO Template
	Attestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
	Claim Count Verification Acknowledgment and Action Form, 10-1-2014
	Data Certification and Validation Report Form, 10-1-2014
	DSN DCO Provider Capacity Report Instructions and Template 2021
	Enrollment Reconciliation Certification - Discrepancies Found, 10-1-2014
	Enrollment Reconciliation Certification – No Discrepancies, 10-1-2014
	FWA Deliverables Review Template CY 2021
	FWA Referrals and Investigations Report Template for CY 2021, 03-2021
	Grievance and Appeal Policy Review
	Grievance and Appeals Exhibit I Deliverable Master v.3
	Grievance System Report
	Grievance System Reporting Instructions
	Language Access Quarterly Report Instructions 03-2020
	Model Depository Agreement for DCOs
	Subcontractor and Delegated Work Report Attestation, 12-2020
	Subcontractor and Delegated Work Report Template, 01-2021