MedicaidAdministrativeMedium impact
26-812 Division of Financial Responsibility Guidelines for Post-Transplant Services
Health Net·CA · Transplant Surgery·Provider News
We identified it
Jun 30, 2026
Summary
Health Net has updated its Division of Financial Responsibility (DOFR) guidelines to clarify financial responsibility for post-transplant services. For the first 365 days post-discharge, transplant-related services billed by the transplant team/facility are Health Net's responsibility, while non-transplant services billed by other providers are the responsibility of the participating physician group or Health Net. After 1 year, all services revert to standard DOFR categories. Billing teams must verify which entity bears financial responsibility based on rendering provider, service type, and days post-discharge.
Action Required
Immediately: Billing team must implement post-transplant service classification logic in billing system to determine financial responsibility based on: (1) rendering provider type (transplant team/facility vs. other provider), (2) service classification (transplant-related vs. non-transplant-related), and (3) days post-discharge (0-365 days vs. >365 days). Update claim submission rules to route transplant-related services from transplant teams to Health Net for payment, and non-transplant services from other providers to participating physician group or Health Net per DOFR. For claims >365 days post-discharge, apply standard DOFR guidelines. Obtain detailed transplant service definitions from the Medi-Cal Provider Operations Manual (accessed via Provider Library > Medi-Cal > Provider Manual > Benefits > Transplants). Train billing staff on new categorization requirements. Failure to correctly apply these rules may result in claim denials or improper payment routing.