DCO Contract Forms

Overview

The dental care organization (DCO) contracts with the Oregon Health Authority (OHA) require DCOs to submit various reports. Templates, related forms and documents for these reports are listed here.

For contract year 2022 due dates, please refer to Exhibit D, Attachment 1 of the 2022 contract.
Please ensure DCO member material meets applicable requirements outlined in Contract and on the Materials Review and Submission page.

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.

Financial Reports

Other Reports

Type	URL
	Attestation Form for Previously Approved Documents, CY 2022 05-2022
	Claim Count Verification Acknowledgment and Action Form, 10-1-2014
	Data Certification and Validation Report Form, 10-1-2014
	DCO Member Transition and Close-Out Plan, 6-2022
	Delegation Authorization and Signature Form, 05-2021 (PDF)
	Delegation Authorization and Signature Form, 05-2021 (Word)
	DSN Annual Provider Narrative Instructions, 05-2021
	DSN Annual Provider Narrative Template, 05-2021
	Enrollment Reconciliation - Discrepancies Found Report, 05-2021
	Enrollment Reconciliation Certification - Discrepancies Found, 05-2021
	Enrollment Reconciliation Certification - No Discrepancies Found, 05-2021
	FWA Audit Report Template for CY 2023, 01-2023
	FWA Deliverables Review Template CY 2021
	FWA Deliverables Review Template CY 2022
	FWA Program Integrity Glossary of Terms, 01-2022
	Grievance System Report
	Grievance System Reporting Instructions
	Health Equity Assessment Template, 07-2022
	Language Access Quarterly Report Instructions 03-2020
	Language Access Taglines_OHP Medicaid CCO Letters_15 languages
	Language Self-Assessment Template, 12-2021
	Model Depository Agreement for DCOs
	Third-Party Liability Recovery P&P Evaluation Criteria, 04-2022

Disclaimer

This page is only for DCOs whose direct contracts with OHA ended December 31, 2022. DCOs should only use the documents on this page if required for their contract close-out activities with OHA.

DCOs subcontracted by coordinated care organizations (CCOs) must contact their CCO for information about deliverables documents that may apply to their subcontract.

Contract Template

2022