Skip to main content Homepage

DCO Contract Forms


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

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.

2020-Exhibit-L-Financial-Reporting-DCO-Template.xlsx2020 Exhibit L Financial Reporting DCO Template
DCO-Attestation-of-Revision-and-Submission-Reporting.docAttestation of Revision and Submission of Contractually Required Reporting, 10-1-2014
DCO-Claim-Count-Verification-Acknowledgment-Action-Form.docClaim Count Verification Acknowledgment and Action Form, 10-1-2014
DCO-Data-Certification-Validation-Report-Form.docData Certification and Validation Report Form, 10-1-2014
DSN DCO Provider Capacity Report Instructions and Template 2021.xlsxDSN DCO Provider Capacity Report Instructions and Template 2021
DCO-Enrollment-Reconciliation-Certification-Discrepancies-Found.xlsxEnrollment Reconciliation Certification - Discrepancies Found, 10-1-2014
DCO-Enrollment-Reconciliation-Certification–No-Discrepancies.docEnrollment Reconciliation Certification – No Discrepancies, 10-1-2014
DCO-FWA-Deliverables-Review-CY2021.docxFWA Deliverables Review Template CY 2021
FWA-Referrals-Investigations-Report-0321.xlsxFWA Referrals and Investigations Report Template for CY 2021, 03-2021
Grievance-Appeal-Policy-Review.xlsxGrievance and Appeal Policy Review
DCO Grievance and Appeals Exhibit I Deliverable Master v.3.zipGrievance and Appeals Exhibit I Deliverable Master v.3
DCO-Grievance-System-Report.docxGrievance System Report
DCO-Grievance-System-Reporting-Instructions.docxGrievance System Reporting Instructions
DCO-Language-Access-Quarterly-Report-Instructions.xlsxLanguage Access Quarterly Report Instructions 03-2020
Model-Depository-Agreement-for-DCOs.docxModel Depository Agreement for DCOs
DCO-Subcontractor-Delegated-Work-Report-Attestation.docxSubcontractor and Delegated Work Report Attestation, 12-2020
DCO-Subcontractor-Delegated-Work-Report.xlsxSubcontractor and Delegated Work Report Template, 01-2021

Your browser is out-of-date! It has known security flaws and may not display all features of this and other websites. Learn how