26-814 Division of Financial Responsibility Guidelines for Post-Transplant Services

Immediately: Billing team must update claim routing logic and financial responsibility assignments in billing software for all post-transplant Medi-Cal claims in Imperial County. For claims dated 0-365 days post-transplant discharge: (1) Route transplant-related services billed by designated transplant teams/facilities to Health Net for payment responsibility; (2) Route all non-transplant services by non-transplant providers to the participating physician group or Health Net per standard DOFR rules. After 1 year post-discharge, route all services under standard DOFR categorization. Update claim scrubber rules to enforce correct financial responsibility coding based on post-transplant timeframe. Train billing staff on the three-tier financial responsibility framework. Audit existing post-transplant claim batches to identify any routed under previous guidance and resubmit under new DOFR clarification. Contact Community Health Plan of Imperial Valley at 833-236-4141 with questions. Failure to correctly apply DOFR may result in claim denials or inappropriate write-offs.