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When a CCO is found to be out of compliance with state or federal requirements, the Oregon Health Authority issues a notice of noncompliance. The CCO must develop and implement a corrective action plan to correct the issues outlined in the notice of noncompliance.
The U.S. Department of Health & Human Services Office of Inspector General (OIG) interviewed four of Oregon’s 15 CCOs and audited their compliance with federal Medicaid managed care regulations for calendar years 2016 and 2017. The Oregon Health Authority (OHA) agreed with the audit’s findings. As noted in the response, the agency has made changes to program oversight and through its CCO 2.0 contracts that address the audit’s compliance concerns.
All Grievance and Appeal System evaluation criteria and templates are posted on the CCO Contract Forms page.
For general guidance, please see the
Material Submissions and Reviews page.
Please see templates below for Notice of Adverse Benefit Determination and Notice of Appeal Resolution. These templates were updated in September 2022.
NOABD Workgroup Questions and Answers
Summary of Denial Notice Template Survey Feedback
Denial Notice Template Survey Questions
Full Denial Notice Template Survey Feedback - June 21 2021
OHA works to develop Network Adequacy Standards that are in alignment with 42 CFR 438.68(c), 42 CFR 438.206 and 438.207, OAR 410-141-3515, and Exhibit G in the CCO Contract.
Oregon is changing its rules for time and distance to providers. Learn more about proposed change and how to give your feedback on the
Time and Distance Rules page.
The Quality Assurance team creates a handbook template for CCOs to use called the Model Member Handbook. The model handbook and the handbook evaluation criteria is updated every year in June.
The CCO Quality Assurance team is coordinating efforts to examine CCO Contract Deliverables and find opportunities to reduce administrative burden, reduce duplication, and improve the overall process.
Part of these efforts included surveying CCO and OHA staff about their experiences and their opinions regarding restructuring deliverables.
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