26-813 Division of Financial Responsibility Guidelines for Post-Transplant Services

Immediately: Billing team must update financial responsibility assignment logic in billing system for all Medi-Cal post-transplant claims in Fresno, Kings, and Madera counties. (1) For claims dated 0-365 days post-discharge: Route transplant-related services rendered by designated transplant team/facility to Health Net for payment responsibility; route all non-transplant services by other providers to participating physician group or Health Net per contract. (2) For claims dated >365 days post-discharge: Apply standard DOFR to all services regardless of rendering provider. (3) Update claim edits and denial protocols to ensure claims are routed to correct responsible party based on service type, provider type, and post-discharge timeframe. (4) Train billing staff to identify transplant-related vs. non-transplant services when assigning financial responsibility. Contact CalViva Health at 888-893-1569 for clarification on specific claim scenarios. Failure to apply correct financial responsibility will result in claim denials and payment delays.