Managed Care Organization (MCO) Reports

The terms of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract, section 18.5(a)(viii)(F), require Managed Care Organizations (MCOs) to submit a Provider Investigative Report to the Office of the Medicaid Inspector General (OMIG) and the Department of Health (DOH) monthly.

The Provider Investigative Report informs OMIG and DOH of any Medicaid provider investigative, educational, or re-educational activities performed by the MCO or its subcontractors, including all overpayments recovered. In addition to reporting investigative activities, the MCO must also upload copies of all Medicaid-related settlement agreements.

This guidance has been updated and is current with the terms of the March 1, 2019, as amended March 1, 2020, and April 1, 2021, Medicaid Managed Care/Family Health Plus/HIV Special Needs/Health and Recovery Plan Model Contract and subsequent agreements.

• View the 2025 Medicaid Managed Care Provider Investigative Report Reporting Instructions & Guidelines.

Monthly Submission Schedule

The Provider Investigative Report must be completed and submitted monthly. Each monthly report is due in accordance with the following submission schedule. Note: When the due date falls on a non-business day, the report is due on the following business day. 

The terms of the Medicaid Advantage Plus, PACE and Partial Capitation Plans Model Contracts, require Managed Long Term Care Organizations (MLTCs) to submit a Provider Investigative Report to the Office of the Medicaid Inspector General (OMIG) and the Department of Health (DOH) quarterly.

• Medicaid Advantage Plus, Section 18.5(c)(xiii)
• PACE, Article VI(E)(3)(o)
• Partial Capitation, Section VIII(F)(3)(s)

The Provider Investigative Report informs OMIG and DOH of any Medicaid provider investigative, educational, or re-educational activities performed by the MLTC or its subcontractors, including all overpayments recovered. In addition to reporting investigative activities, the MLTC must also upload copies of all Medicaid-related settlement agreements.

This guidance has been updated and is current with the terms of the MAP, PACE and Partial Capitation Model Contracts. 

• View the 2025 Medicaid Managed Care MLTC Provider Investigative Report Reporting Instructions & Guidelines.

Additionally, please find a recording from a training held for MLTCs regarding the completion of the Provider Investigation Report.

• View the 2025 MLTC Provider Investigative Reporting Training Recording.

Quarterly Submission Schedule 

The Provider Investigative Report must be completed and submitted quarterly. Each quarterly report is due in accordance with the following submission schedule. Note: When the due date falls on a non-business day, the report is due on the following business day. 

The Comprehensive Provider Report is a quarterly report identifying the value of claims, payments, referrals, orders, and prescriptions made for members of a Medicaid Managed Care (MMC) Plan. The March 1, 2014 Medicaid Managed Care Model Contract identifies the report requirements in section 18.5 a. xviii. Managed Care Plans submit the required reports quarterly via the NYS Health Commerce System.

The submission timeline is as follows:

Please download each of the three documents below by clicking the link.

Comprehensive Provider Report Date Dictionary - Defines the form and format of the Comprehensive Provider Report. Includes report terms and definitions, data element descriptions & examples, and file naming conventions.

V1.1 Released August 1, 2015

Comprehensive Provider Report Submission and Validation Guidance - Outlines the Comprehensive Provider Report submission process. Includes validation error code & description list. 

V1.1 Released August 1, 2015

Comprehensive Plan Total Summary File Template – Excel format template. Save a copy to populate with the Comprehensive Plan Total Summary File data each Quarter. 

V1.1 Released August 1, 2015

Any questions regarding the Comprehensive Provider Report should be sent via email to [email protected].