42 U.S.C. § 1395gg : US Code - Section 1395GG: Overpayment on behalf of individuals and settlement of claims for benefits on behalf of deceased individuals

Search 42 U.S.C. § 1395gg : US Code - Section 1395GG: Overpayment on behalf of individuals and settlement of claims for benefits on behalf of deceased individuals

(a) Payments to providers of services or other person regarded as
payment to individuals
Any payment under this subchapter to any provider of services or
other person with respect to any items or services furnished any
individual shall be regarded as a payment to such individual.
(b) Incorrect payments on behalf of individuals; payment adjustment
Where -
(1) more than the correct amount is paid under this subchapter
to a provider of services or other person for items or services
furnished an individual and the Secretary determines (A) that,
within such period as he may specify, the excess over the correct
amount cannot be recouped from such provider of services or other
person, or (B) that such provider of services or other person was
without fault with respect to the payment of such excess over the
correct amount, or
(2) any payment has been made under section 1395f(e) of this
title to a provider of services or other person for items or
services furnished an individual,
proper adjustments shall be made, under regulations prescribed
(after consultation with the Railroad Retirement Board) by the
Secretary, by decreasing subsequent payments -
(3) to which such individual is entitled under subchapter II of
this chapter or under the Railroad Retirement Act of 1974 [45
U.S.C. 231 et seq.], as the case may be, or
(4) if such individual dies before such adjustment has been
completed, to which any other individual is entitled under
subchapter II of this chapter or under the Railroad Retirement
Act of 1974 [45 U.S.C. 231 et seq.], as the case may be, with
respect to the wages and self-employment income or the
compensation constituting the basis of the benefits of such
deceased individual under subchapter II of this chapter.
As soon as practicable after any adjustment under paragraph (3) or
(4) is determined to be necessary, the Secretary, for purposes of
this section, section 1395i(g) of this title, and section 1395t(f)
of this title, shall certify (to the Railroad Retirement Board if
the adjustment is to be made by decreasing subsequent payments
under the Railroad Retirement Act of 1974 [45 U.S.C. 231 et seq.])
the amount of the overpayment as to which the adjustment is to be
made. For purposes of clause (B) of paragraph (1), such provider of
services or such other person shall, in the absence of evidence to
the contrary, be deemed to be without fault if the Secretary's
determination that more than such correct amount was paid was made
subsequent to the third year following the year in which notice was
sent to such individual that such amount had been paid; except that
the Secretary may reduce such three-year period to not less than
one year if he finds such reduction is consistent with the
objectives of this subchapter.
(c) Exception to subsection (b) payment adjustment
There shall be no adjustment as provided in subsection (b) of
this section (nor shall there be recovery) in any case where the
incorrect payment has been made (including payments under section
1395f(e) of this title) with respect to an individual who is
without fault or where the adjustment (or recovery) would be made
by decreasing payments to which another person who is without fault
is entitled as provided in subsection (b)(4) of this section, if
such adjustment (or recovery) would defeat the purposes of
subchapter II or subchapter XVIII of this chapter or would be
against equity and good conscience. Adjustment or recovery of an
incorrect payment (or only such part of an incorrect payment as the
Secretary determines to be inconsistent with the purposes of this
subchapter) against an individual who is without fault shall be
deemed to be against equity and good conscience if (A) the
incorrect payment was made for expenses incurred for items or
services for which payment may not be made under this subchapter by
reason of the provisions of paragraph (1) or (9) of section
1395y(a) of this title and (B) if the Secretary's determination
that such payment was incorrect was made subsequent to the third
year following the year in which notice of such payment was sent to
such individual; except that the Secretary may reduce such three-
year period to not less than one year if he finds such reduction
is consistent with the objectives of this subchapter.
(d) Liability of certifying or disbursing officer for failure to
recoup
No certifying or disbursing officer shall be held liable for any
amount certified or paid by him to any provider of services or
other person where the adjustment or recovery of such amount is
waived under subsection (c) of this section or where adjustment
under subsection (b) of this section is not completed prior to the
death of all persons against whose benefits such adjustment is
authorized.
(e) Settlement of claims for benefits under this subchapter on
behalf of deceased individuals
If an individual, who received services for which payment may be
made to such individual under this subchapter, dies, and payment
for such services was made (other than under this subchapter), and
the individual died before any payment due him under this
subchapter with respect to such services was completed, payment of
the amount due (including the amount of any unnegotiated checks)
shall be made -
(1) if the payment for such services was made (before or after
such individual's death) by a person other than the deceased
individual, to the person or persons determined by the Secretary
under regulations to have paid for such services, or if the
payment for such services was made by the deceased individual
before his death, to the legal representative of the estate of
such deceased individual, if any;
(2) if there is no person who meets the requirements of
paragraph (1), to the person, if any, who is determined by the
Secretary to be the surviving spouse of the deceased individual
and who was either living in the same household with the deceased
at the time of his death or was, for the month in which the
deceased individual died, entitled to a monthly benefit on the
basis of the same wages and self-employment income as was the
deceased individual;
(3) if there is no person who meets the requirements of
paragraph (1) or (2), or if the person who meets such
requirements dies before the payment due him under this
subchapter is completed, to the child or children, if any, of the
deceased individual who were, for the month in which the deceased
individual died, entitled to monthly benefits on the basis of the
same wages and self-employment income as was the deceased
individual (and, in case there is more than one such child, in
equal parts to each such child);
(4) if there is no person who meets the requirements of
paragraph (1), (2), or (3), or if each person who meets such
requirements dies before the payment due him under this
subchapter is completed, to the parent or parents, if any, of the
deceased individual who were, for the month in which the deceased
individual died, entitled to monthly benefits on the basis of the
same wages and self-employment income as was the deceased
individual (and, in case there is more than one such parent, in
equal parts to each such parent);
(5) if there is no person who meets the requirements of
paragraph (1), (2), (3), or (4), or if each person who meets such
requirements dies before the payment due him under this
subchapter is completed, to the person, if any, determined by the
Secretary to be the surviving spouse of the deceased individual;
(6) if there is no person who meets the requirements of
paragraph (1), (2), (3), (4), or (5), or if each person who meets
such requirements dies before the payment due him under this
subchapter is completed, to the person or persons, if any,
determined by the Secretary to be the child or children of the
deceased individual (and, in case there is more than one such
child, in equal parts to each such child);
(7) if there is no person who meets the requirements of
paragraph (1), (2), (3), (4), (5), or (6), or if each person who
meets such requirements dies before the payment due him under
this subchapter is completed, to the parent or parents, if any,
of the deceased individual (and, in case there is more than one
such parent, in equal parts to each such parent); or
(8) if there is no person who meets the requirements of
paragraph (1), (2), (3), (4), (5), (6), or (7), or if each person
who meets such requirements dies before the payment due him under
this subchapter is completed, to the legal representatives of the
estate of the deceased individual, if any.
(f) Settlement of claims for section 1395k benefits on behalf of
deceased individuals
If an individual who received medical and other health services
for which payment may be made under section 1395k(a)(1) of this
title dies, and no assignment of the right to payment for such
services was made by such individual before his death, and payment
for such services has not been made -
(1) if the person or persons who furnished the services agree
to the terms of assignment specified in section
1395u(b)(3)(B)(ii) of this title with respect to the services,
payment for such services shall be made to such person or
persons, and
(2) if the person or persons who furnished the services do not
agree to the terms of assignment specified in section
1395u(b)(3)(B)(ii) of this title with respect to the services,
payment for such services shall be made on the basis of an
itemized bill to the person who has agreed to assume the legal
obligation to make payment for such services and files a request
for payment (with such accompanying evidence of such legal
obligation as may be required in regulations),
but only in such amount and subject to such conditions as would be
applicable if the individual who received the services had not
died.
(g) Refund of premiums for deceased individuals
If an individual, who is enrolled under section 1395i-2(c) of
this title or under section 1395p of this title, dies, and premiums
with respect to such enrollment have been received with respect to
such individual for any month after the month of his death, such
premiums shall be refunded to the person or persons determined by
the Secretary under regulations to have paid such premiums or if
payment for such premiums was made by the deceased individual
before his death, to the legal representative of the estate of such
deceased individual, if any. If there is no person who meets the
requirements of the preceding sentence such premiums shall be
refunded to the person or persons in the priorities specified in
paragraphs (2) through (7) of subsection (e) of this section.
(h) Appeals by providers of services or suppliers
Notwithstanding subsection (f) of this section or any other
provision of law, the Secretary shall permit a provider of services
or supplier to appeal any determination of the Secretary under this
subchapter relating to services rendered under this subchapter to
an individual who subsequently dies if there is no other party
available to appeal such determination.