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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.

 View CCO contract announcements

Financial Reports

Other Reports

URL
  
Modified
  
Deliverable type
  
2024 Insolvency Plan Guidance7/2/2024 5:25 PMOperations
2024 Insolvency Plan Template7/2/2024 5:25 PMOperations
2025 Care Coordination Policies Procedures Evaluation Criteria Template11/14/2024 11:41 AMCare Coordination
2025 NOAR Final_Clean Version_v210/29/2024 5:45 PMMember Materials
2025 NOAR Final_Redlined_v210/29/2024 5:45 PMMember Materials
2025 Post-service NOABD Final_Clean Version_v210/29/2024 5:40 PMMember Materials
2025 Post-service NOABD Final_Redlined_v210/29/2024 5:45 PMMember Materials
2025 Regular NOABD Final_Clean Version_v210/29/2024 5:45 PMMember Materials
2025 Regular NOABD Final_Redlined_v210/29/2024 5:50 PMMember Materials
Affiliated Medicare Advantage Plan Guidance 20259/3/2024 5:05 PMOperations
Affiliated Medicare Advantage Plan Report Template 20259/3/2024 5:15 PMOperations
Allowed Amount Guidance Document, 01-20231/18/2023 12:20 PMEnrollment and Encounter Data
Attestation for PA Determinations for SUD Services - 20242/15/2024 6:10 PMBehavioral Health
Behavioral Health Directed Payment FAQ for CY 20243/7/2024 4:50 PMBehavioral Health
Behavioral Health Directed Payment Guidance Document for CY 20243/7/2024 4:50 PMBehavioral Health
Behavioral Health P&P attestation form 202511/21/2024 10:45 AMBehavioral Health
Behavioral Health P&P Evaluation Criteria 202511/15/2024 4:55 PMBehavioral Health
Behavioral Health Report Measurement Template, 07-2022 (corrected 9/28/2022)2/15/2024 6:20 PMBehavioral Health
Care Coordination Report Template, 06-20232/15/2024 6:13 PMCare Coordination
CBHP Evaluation Criteria 202410/2/2024 5:48 PMBehavioral Health
CBHP Progress Reporting Implementation Guide 202410/2/2024 5:56 PMBehavioral Health
CBHP Progress Reporting Template 202410/2/2024 5:57 PMBehavioral Health
CCO Deliverables Portal Training with account setup information10/18/2023 1:50 PMGeneral
CCO Language Self-Assessment Instructions and Response Template_202412/16/2024 4:50 PMOperations
CCO Portal Frequently Asked Questions1/24/2024 8:35 AMGeneral
CCO Welcome Packet and Annual Letter Evaluation Criteria 20257/5/2024 1:45 PMMember Materials
Checklist for Medicaid Member Materials7/9/2024 5:35 PMMember Materials
Claim Count Verification Acknowledgment and Action Form, 10-1-20146/29/2022 4:40 PMEnrollment and Encounter Data
CMS DUR Survey FFY 2022 – INFORMATIONAL COPY4/19/2023 4:05 PMPharmacy and Drug Utilization
Compare-2025-Decision-Final-M.pdf11/4/2024 3:30 PMBehavioral Health
Compare-Final-2024-Final-2025-M.pdf11/4/2024 3:30 PMBehavioral Health
Data Certification and Validation Report Form, 10-1-20146/29/2022 4:40 PMGeneral
Delegation Authorization and Signature Form, 11/19/202411/19/2024 2:30 PMOperations
Dental Directed Payment Incentive Guidance and FAQ, 12/202412/16/2024 1:15 PMFinancial
DSN Evaluation Protocol, CY 20245/1/2024 1:30 PMNetwork Adequacy
DSN Evaluation Reporting Template, CY 20245/1/2024 1:30 PMNetwork Adequacy
DSN Material Change Notification Form2/15/2024 6:15 PM
DSN Narrative Evaluation TA FAQ, CY 20245/29/2024 3:20 PMNetwork Adequacy
DSN Provider Capacity Feedback and OHA Response to Reporting, CY 20239/30/2022 1:16 PMDelivery System Network
DSN Provider Capacity Report Instructions August 202410/3/2024 8:41 AMNetwork Adequacy
DSN Provider Capacity Report Instructions, CY202510/2/2024 6:05 PMNetwork Adequacy
DSN Provider Capacity Report Template and Instructions, August 202410/3/2024 8:41 AMNetwork Adequacy
DSN Provider Capacity Report Template and Instructions, CY 202510/2/2024 6:06 PMNetwork Adequacy
DSN Provider Specialty Matrix, August 20248/7/2024 3:20 PMNetwork Adequacy
DSN Time and Distance Exception Request Process and Form, CY 20245/13/2024 2:31 PMNetwork Adequacy
DSN Time and Distance Exception Request Process FAQ, 06/14/20246/14/2024 10:05 AMNetwork Adequacy
Enrollment Reconciliation - Discrepancy Reporting Guide, June 20216/29/2022 4:55 PMEnrollment and Encounter Data
Enrollment Reconciliation Certification – No Discrepancies, 10-1-201411/19/2024 8:30 AM
EPSDT Guidance Document, 10/202410/25/2024 2:25 PMCare Coordination
Family Connects Oregon Evaluation Criteria 20248/6/2024 4:15 PMCommunity Engagement
Family Connects Oregon Guidance for CCOs 20248/6/2024 4:15 PMCommunity Engagement
Fraud Waste and Abuse (FWA) Annual Guidance Document 202411/1/2023 9:55 AMFraud, Waste, and Abuse
Fraud Waste and Abuse (FWA) Annual Guidance Document 202511/6/2024 8:55 AMFraud, Waste & Abuse
Fraud Waste and Abuse (FWA) Annual Template 20242/15/2024 6:15 PM
Fraud Waste and Abuse (FWA) Annual Template 202511/1/2024 12:00 PMFraud, Waste & Abuse
FWA Annual Assessment Report - Attestation for Previously Submitted Documents, 11-20222/15/2024 6:20 PM
FWA Audit Report Template for CY 2024, 02-20243/6/2024 2:19 PMFraud, Waste & Abuse
FWA Deliverables Review Template, CY 2024 (OPI)11/1/2024 9:40 AMFraud, Waste & Abuse
FWA Deliverables Review Template, CY 2025 (OPI)10/3/2024 6:05 PMFraud, Waste & Abuse
FWA Fraud Waste and Abuse FAQ 20231/24/2023 9:45 AMFraud, Waste, and Abuse
FWA Program Integrity Glossary of Terms, 01-20226/29/2022 4:45 PMFraud, Waste, and Abuse
FWA Referral Form10/3/2024 6:06 PMFraud, Waste & Abuse
FWA Referrals and Investigations Report Template for CY 2024, 02-20243/25/2024 11:00 AM
FWA Referrals and Investigations Report Template for CY 202510/3/2024 6:06 PMFraud, Waste & Abuse
FWA-Audit-Report- CY 202510/3/2024 6:05 PMFraud, Waste & Abuse
Grievance and Appeal - Appeal Log 202510/2/2024 5:42 PMGrievances & Appeals
Grievance and Appeal - Grievance Log 202510/2/2024 5:41 PMGrievances & Appeals
Grievance and Appeal - NOABDLog 202510/2/2024 5:41 PMGrievances & Appeals
Grievance and Appeal - PA Log 202510/2/2024 5:37 PMGrievances & Appeals
Grievance and Appeal Log Reporting Instructions 202510/2/2024 5:42 PMGrievances & Appeals
Grievance and Appeal Log_Redline 202510/2/2024 5:06 PMGrievances & Appeals
Grievance and Appeal System Code Tables 202510/16/2024 10:30 AMGrievances & Appeals
Grievance and Appeal System P&Ps Attestation, 2-29-20243/5/2024 9:55 AMGrievances & Appeals
Grievance and Appeal System Policies and Procedures Evaluation Criteria, 20242/15/2024 6:05 PMGrievances & Appeals
Grievance System Code Tables 202310/22/2024 1:05 PMGrievances & Appeals
Grievance System Code Tables 20242/15/2024 6:00 PMGrievances & Appeals
Grievance System Reporting Instructions 202310/22/2024 1:05 PMGrievances & Appeals
Health Equity Plan Evaluation Tool, 04-20244/3/2024 10:05 AMHealth Equity
Health Equity Plan Guidance Document, 04-20244/3/2024 10:05 AMHealth Equity
Health Equity Plan Report Template, 04-20244/3/2024 10:05 AMHealth Equity
Health Equity Plan Training and Education Reporting Template, 04-20244/3/2024 10:09 AMHealth Equity
Health IT Roadmap Guidance and Report Template Final12/16/2024 4:55 PMHealth Information Systems
Health Risk Assessment Evaluation Criteria, CY 20257/17/2024 4:55 PMCare Coordination
Health-Related Services and 2022-2027 OHP Waiver Updates, May 20246/3/2024 9:20 AMCare Coordination
Health-Related Services Exhibit L Financial Reporting Template Guidance, May 20246/3/2024 9:25 AMFinancial
Health-Related Services Policy and Procedure Evaluation Criteria 20249/5/2024 2:55 PMHealth Equity
Hep C DAA CY 2023 Case Management Data Template2/15/2024 6:20 PM
Hep C DAA Risk Corridor – Final Definition of Adequate Case Management, 20231/10/2023 2:10 PMHepatitis C
HRSN Climate and O&E Services Readiness Review Template 20249/5/2024 3:00 PMCare Coordination
HRSN Clinical Risk Factors Code Crosswalk, 09-20249/6/2024 9:50 AMOperations
HRSN Guidance Document, 09/20249/9/2024 9:25 AMOperations
HRSN Housing and Outreach Engagement Readiness Plan Template10/11/2024 6:05 PMOperations
HRSN Nutrition Readiness Plan Template11/6/2024 5:05 PMOperations
IIBHT 60 Day Plan OHA evaluation template10/15/2024 11:35 AMBehavioral Health
IIBHT Quarterly Report OHA Evaluation Template 202510/3/2024 1:11 PMBehavioral Health
IIBHT Quarterly Report Template 202510/11/2024 5:50 PMBehavioral Health
Indian Health Care Provider Reimbursement Guidance for 2024, 1/9/20247/25/2024 10:25 AMOperations
Indian Health Care Provider reimbursement Guidance for 2025, 10/202410/10/2024 4:48 PMOperations
Language Access and Interpreter Services Report Instructions, 09/20222/15/2024 6:20 PM
Language Access and Interpreter Services Report Instructions, 12/19/20232/15/2024 6:05 PMGrievances & Appeals
Language Access Self-Assessment Survey (Reference Copy), 12-202212/19/2022 9:40 AMLanguage Access
Language Access Taglines_OHP Medicaid CCO Letters_15 languages10/15/2024 6:05 PMMember Materials
LTPC Determinations for Ages 18-64 - Request Process and Form, revised 10-1-20146/29/2022 4:40 PMBehavioral Health
LTPC Determinations for Neuropsychiatric Treatment - Request Process and Form, revised 10-1-20146/29/2022 4:40 PMBehavioral Health
LTPC Long-Term Psychiatric Care Determinations for Ages 17 and Under12/20/2024 8:50 AMBehavioral Health
LTPC Long-Term Psychiatric Care Fact Sheet12/20/2024 8:50 AMBehavioral Health
LTSS CCO-Specific Guidance: Annual MOU and Reporting, 11-202212/8/2022 3:15 PMLong Term Services and Supports
LTSS Memorandum of Understanding Guidance, CY 2020-2412/2/2022 2:45 PMLong Term Services and Supports
LTSS Memorandum of Understanding Template, CY 2020-242/15/2024 6:20 PM
LTSS MOU Guidance on Sharing Information 12-202012/2/2022 2:25 PMLong Term Services and Supports
LTSS MOU Report Template - CY 20222/15/2024 6:20 PM
LTSS MOU Report Template - CY 20245/13/2024 2:25 PMCare Coordination
MCIS Guidance for CCOs, 12/202312/12/2023 9:30 AMBehavioral Health
Measures and Outcomes Tracking System (MOTS), 10-1-20146/29/2022 4:40 PMBehavioral Health
Member Handbook - CCO Model Handbook - 2025 Redline version5/31/2024 3:10 PMMember Materials
Member Handbook - CCO Model Member Handbook - 2025 No Markup version10/1/2024 4:45 PMMember Materials
Member Handbook Evaluation Criteria 20255/31/2024 3:10 PMMember Materials
Member Handbook Insert for OHP Bridge starting July 1 20243/1/2024 12:00 PMMember Materials
Member Handbook Submission and Review Guidelines 20255/31/2024 3:10 PMMember Materials
Member Materials Submission Guide for the CCO Deliverables Portal10/16/2024 9:05 AMMember Materials
Member Notice Template Self-Evaluation Checklist for CY 202510/2/2024 6:11 PMMember Materials
Member Notice Template Self-Evaluation Checklist for CY 202510/29/2024 5:44 PMGrievances & Appeals
Member Notice Templates Attestation for CY202510/2/2024 6:13 PMMember Materials
Mental Health Parity Data Submission Template 20243/1/2024 1:25 PMExternal Quality Review
Mental Health Parity Evaluation Data Submission Template 20232/15/2024 6:15 PM
Mental Health Parity Evaluation Protocol 20236/6/2023 9:05 AMMental Health Parity
Mental Health Parity Evaluation Treatment Limitation Review Tool 20232/15/2024 6:15 PM
Mental Health Parity Protocol 20243/1/2024 1:25 PMExternal Quality Review
Mental Health Parity Treatment Limitation Attestation Tool 20243/1/2024 1:25 PMExternal Quality Review
Minimum Standards for DUR Programs, effective 10-20196/29/2022 4:55 PMPharmacy and Drug Utilization
Minimum Standards for DUR Programs, effective 7-20216/29/2022 4:55 PMPharmacy and Drug Utilization
NEMT Call Center Script Attestation 202511/27/2024 9:25 PMNEMT/Transportation
NEMT Call Center Script Attestation for CY 20242/15/2024 6:10 PM
NEMT Call Center Script Self-Evaluation Checklist for CY 20242/15/2024 6:10 PM
NEMT Call Center Script Self-Evaluation Checklist for CY 202511/27/2024 9:25 PMNEMT/Transportation
NEMT Policies and Procedures Attestation for CY 202511/1/2024 3:00 PMNEMT/Transportation
NEMT Policies and Procedures Self-Evaluation Checklist for CY 202511/1/2024 3:00 PMNEMT/Transportation
NEMT Quarterly QA Reporting Template - Technical Specifications, Q2 202410/2/2024 3:21 PMNEMT/Transportation
NEMT Quarterly QA Reporting Template - Technical Specifications, Q1 202510/3/2024 6:10 PMNEMT/Transportation
NEMT Quarterly QA Reporting Template, Q1 202510/3/2024 6:11 PMNEMT/Transportation
NEMT Quarterly QA Reporting Template, Q2 202410/2/2024 3:20 PMNEMT/Transportation
NEMT Rider Guide Evaluation Criteria 20256/25/2024 4:30 PMNEMT/Transportation
NEMT Rider Guide Submission and Review Guidelines, 20256/25/2024 4:30 PMNEMT/Transportation
NEMT-NOABD-Content10/29/2024 5:45 PMGrievances & Appeals
NOABD and Prior Authorization sample evaluation criteria 20242/13/2024 12:10 PMGrievances & Appeals
NOABD and Prior Authorization Sample Evaluation Criteria 2025 Final w Redlines_v210/29/2024 5:45 PMGrievances & Appeals
NOABD and Prior Authorization Sample Evaluation Criteria 2025 Final_Clean Version_v210/29/2024 5:45 PMGrievances & Appeals
OHA attestation form for Applied Behavior Analysis CY192/15/2024 6:25 PM
OHP Bridge - Basic Health Program Hospital Guidance, 12-202412/19/2024 9:35 AMFinancial
PBM Market Check Report Template7/25/2024 10:15 AMPharmacy Benefits Manager
PBM Pay for Performance Template7/24/2024 5:10 PMPharmacy Benefits Manager
PBM Pay for Performance Template Instructions 06-20247/24/2024 5:05 PMPharmacy Benefits Manager
PBM Readiness Checklist (PDF)6/29/2022 4:40 PMPharmacy and Drug Utilization
PBM Readiness Checklist (Word)3/6/2024 2:35 PMPharmacy Benefits Manager
PCPCH Reporting - Reference Copy and Evaluation Criteria, 10-202310/23/2023 5:05 PMPatient-Centered Primary Care Home
PIL Lien Templates Attestation, 12/1/20232/15/2024 6:05 PMOperations
PIL Lien Templates Self-Evaluation Checklist for CY 2024, 11/29/20233/6/2024 2:30 PMOperations
PIL Monthly Reporting Template2/29/2024 11:25 AMOperations
PIL P&Ps Attestation, 12/1/20233/6/2024 2:30 PMOperations
PIL P&Ps Self-Evaluation Checklist for CY 2024, 11/29/20233/6/2024 2:30 PMOperations
Preferred Drug List Template 202510/18/2024 11:26 AMPharmacy
Quality Pool Distribution Plan Evaluation Criteria, 20247/11/2024 10:45 AMOperations
Quality Pool Distribution Plan Template, 20247/11/2024 10:45 AMOperations
Redaction Log, 06-20223/22/2024 4:30 PM
Risk Stratification Evaluation Critiera, CY 20246/10/2024 5:10 PMCare Coordination
Social Needs Service Coordination Report Guidance, 202510/4/2024 10:25 AMOperations
Social Needs Service Coordination Report Template, 202510/4/2024 10:26 AMOperations
Statewide Performance Improvement Project (PIP) validation tool, 20246/18/2024 2:05 PMQuality Improvement
Subcontractor and Delegated Work Report Attestation, 202512/4/2024 3:25 PMSubcontractor & Provider
Subcontractor and Delegated Work Report Evaluation Criteria, 202512/4/2024 3:20 PMSubcontractor & Provider
Subcontractor and Delegated Work Report Template, 202512/4/2024 3:40 PMSubcontractor & Provider
Subcontractor Compliance Review Tool, 2024 3/29/2024 11:10 AMSubcontractor & Provider
Subcontractor Performance Report Evaluation Criteria with Guidance, 202510/2/2024 9:17 AMSubcontractor & Provider
System of Care P&P Attestation 202511/4/2024 8:55 AMBehavioral Health
System of Care P&Ps Self Evaluation Checklist 202511/1/2024 12:00 PMBehavioral Health
System of Care Statewide Steering Committee Report Template, 03-20202/15/2024 6:20 PMBehavioral Health
System of Care Statewide Steering Committee Report Template, 06-24 (for testing purposes)7/16/2024 11:30 AMBehavioral Health
THW Deliverables Evaluation Criteria, 08-20248/16/2024 10:10 AMHealth Equity
THW Deliverables Guidance, 08-20248/16/2024 10:10 AMHealth Equity
THW Integration and Utilization Data Report Template, 08-202410/10/2024 6:35 PMHealth Equity
THW Integration and Utilization Plan Update Template, 08-20248/16/2024 3:20 PMHealth Equity
THW Payment Grid Template, 10-202410/29/2024 8:05 AMHealth Equity
TPL Reporting Guidance6/29/2022 4:50 PMThird Party Liability
TPLR P&P Evaluation Criteria, 12/1/202312/1/2023 2:16 PMThird Party Liability
TPLR Reporting Guidance, 12/1/202312/1/2023 2:20 PMThird Party Liability
Tracked-Numbered-Final-2025-M.pdf11/4/2024 3:31 PMBehavioral Health
Wraparound P&P Attestation 2025 11/4/2024 8:55 AMBehavioral Health
Wraparound P&Ps Self Evaluation Checklist 202511/1/2024 11:55 AMBehavioral Health
YSHCN Guidance Document, 10/202410/28/2024 2:55 PMOperations



Contract Templates

2025

2024

2023

2022

2021

2020

CCO Portal Login

Resources

Transformation Center guidance and templates

Community Health Assessment (CHA) and Community Health Improvement Plan (CHP)

To learn more, please visit OHA's page for CHA/CHP guidance and training.

Community Advisory Council (CAC)

Health-Related Services (HRS)

To learn more, please visit OHA's Health-Related Services page​.​​​

SHARE Initiative

Guidance Reporting templates

To learn more and find reporting templates, please visit OHA's SHARE Initiative page.

Transformation and Quality Strategy (TQS) 

2024 template

2024 guidance

To learn more, please visit OHA's TQS page.

Value-Based Payments

To learn more, please visit OHA's Value-Based Payment page.

CCO Deliverables Portal
Login to the CCO Portal


Account and System Requests

  • Use the Account Requests form to request a new account or remove an existing account. Accounts are limited to CCO staff.

Training and Documentation

Member Notice templates

​Member Materials

For general guidance, please see the Material Submissions and Reviews page.

NOABD, NOAR templates

Please see templates below for Notice of Adverse Benefit Determination and Notice of Appeal Resolution. These templates were updated in October 2024.


Redline versions:

Notice Workgroup

In Lieu of Services (ILOS)

​In lieu of services (ILOS) are services determined by the state to be medically appropriate and cost-effective substitutes for covered services or settings under the State Medicaid Plan. ILOS must meet requirements outlined in 42 CFR 438.3(e)(2). Please see guidance and resources below:

For more information about ILOS, visit the ILOS page.


Health Related Social Needs (HRSN)

​The 2022-2027 waiver for the Oregon Health Plan (OHP) 1115 Medicaid Demonstration​ includes groundbreaking authority to provide health-related social needs (HRSN) services as a covered OHP benefit to eligible members, including those who are members through the Healthier Oregon program. 

Approved HRSN services include housing, nutrition, climate-related supports, and outreach and engagement services.

  • Find HRSN deliverables and guidance in the "Other Reports" section of this page.
  • Learn more about HRSN on the HRSN page.