42 U.S.C. § 1395gg
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.
Where-
proper adjustments shall be made, under regulations prescribed (after consultation with the Railroad Retirement Board) by the Secretary, by decreasing subsequent payments-
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 fifth 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 five-year period to not less than one year if he finds such reduction is consistent with the objectives of this subchapter.
There shall be no adjustment as provided in subsection (b) (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), if such adjustment (or recovery) would defeat the purposes of subchapter II or subchapter XVIII 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 fifth year following the year in which notice of such payment was sent to such individual; except that the Secretary may reduce such five-year period to not less than one year if he finds such reduction is consistent with the objectives of this subchapter.
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) or where adjustment under subsection (b) is not completed prior to the death of all persons against whose benefits such adjustment is authorized.
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-
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-
but only in such amount and subject to such conditions as would be applicable if the individual who received the services had not died.
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).
Notwithstanding subsection (f) 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.
42 U.S.C. § 1395gg
EDITORIAL NOTES
REFERENCES IN TEXTThe Railroad Retirement Act of 1974, referred to in subsec. (b), is act Aug. 29, 1935, ch. 812, as amended generally by Pub. L. 93-445, title I, §101, Oct. 16, 1974, 88 Stat. 1305, which is classified generally to subchapter IV (§231 et seq.) of chapter 9 of Title 45, Railroads. For further details and complete classification of this Act to the Code, see Codification note set out preceding section 231 of Title 45, section 231t of Title 45, and Tables.
AMENDMENTS2013-Subsecs. (b), (c). Pub. L. 112-240 substituted "fifth year" for "third year" and "five-year" for "three-year" in last sentence.2003-Subsec. (h). Pub. L. 108-173 added subsec. (h).1988- Pub. L. 100-360, §411(e)(3), added Pub. L. 100-203, §4039(h)(7), see 1987 Amendment note below.Subsec. (f)(1), (2). Pub. L. 100-360, §411(j)(4)(B), substituted "of assignment specified in" for "specified in subclauses (I) and (II) of".1987- Pub. L. 100-203, §4039(h)(7), as added by Pub. L. 100-360, §411(e)(3), amended section catchline generally.Subsec. (f)(1), (2). Pub. L. 100-203, §4096(a)(2), substituted "to the terms specified in subclauses (I) and (II) of section 1395u(b)(3)(B)(ii) of this title with respect to the services" for "that the reasonable charge is the full charge for the services". 1982-Subsec. (c). Pub. L. 97-248 substituted "section 1395y(a)" for "section 1395y". 1980-Subsec. (f). Pub. L. 96-499 amended subsec. (f) generally, inserting provision for payments to providers of medical and other health services where the person or persons furnishing the services did not agree that the reasonable charge was the full charge for such services.1974-Subsec. (b). Pub. L. 93-445 substituted "Railroad Retirement Act of 1974" for "Railroad Retirement Act of 1937", wherever appearing. 1972-Subsec. (b). Pub. L. 92-603, §281(a), required that provider of services or other person be without fault with respect to payment of excess over correct amount as prerequisite to adjustment or recovery of incorrect payments. Subsec. (c). Pub. L. 92-603, §§261(a), 281, substituted "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), if" for "and where", inserted reference to subchapter XVIII of this chapter, and inserted provisions covering the adjustment or recovery of incorrect payments against individuals who are without fault. Subsec. (g). Pub. L. 92-603, §266, added subsec. (g). 1968- Pub. L. 90-248, §154(b), provided for settlement of claims for benefits on behalf of deceased individuals in section catchline.Subsecs. (e), (f). Pub. L. 90-248, §154(c), added subsecs. (e) and (f).
STATUTORY NOTES AND RELATED SUBSIDIARIES
EFFECTIVE DATE OF 2013 AMENDMENT Pub. L. 112-240, title VI, §638(b), Jan. 2, 2013, 126 Stat. 2357, provided that: "The amendments made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Jan. 2, 2013]."
EFFECTIVE DATE OF 2003 AMENDMENT Pub. L. 108-173, title IX, §939(b), Dec. 8, 2003, 117 Stat. 2416, provided that: "The amendment made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Dec. 8, 2003] and shall apply to items and services furnished on or after such date."
EFFECTIVE DATE OF 1988 AMENDMENT Except as specifically provided in section 411 of Pub. L. 100-360 amendment by Pub. L. 100-360 as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203 effective as if included in the enactment of that provision in Pub. L. 100-203, see section 411(a) of Pub. L. 100-360 set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
EFFECTIVE DATE OF 1987 AMENDMENT Amendment by section 4096(a)(2) of Pub. L. 100-203 applicable to services furnished on or after Jan. 1, 1988, see section 4096(d) of Pub. L. 100-203 set out as a note under section 1320c-3 of this title.
EFFECTIVE DATE OF 1982 AMENDMENT Amendment by Pub. L. 97-248 effective Sept. 3, 1982, see section 128(e)(3) of Pub. L. 97-248 set out as a note under section 1395x of this title.
EFFECTIVE DATE OF 1980 AMENDMENT Pub. L. 96-499, title IX, §954(b), Dec. 5, 1980, 94 Stat. 2647, provided that: "The amendment made by this section [amending this section] shall apply only to claims filed on or after January 1, 1981."
EFFECTIVE DATE OF 1974 AMENDMENT Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section 603 of Pub. L. 93-445 set out as a note under section 402 of this title.
EFFECTIVE DATE OF 1972 AMENDMENT Pub. L. 92-603, title II, §261(b), Oct. 30, 1972, 86 Stat. 1448, provided that: "The amendment made by subsection (a) [amending this section] shall apply with respect to waiver actions considered after the date of the enactment of this Act [Oct. 30, 1972]." Pub. L. 92-603, title II, §281(g), Oct. 30, 1972, 86 Stat. 1456, provided that: "The provisions of subsection (a)(1) [amending this section] shall apply with respect to notices of payment sent to individuals after the date of enactment of this Act [Oct. 30, 1972]. The provisions of subsections (a)(2), (b), (c), and (d) [amending this section and sections 1395u and 1395cc of this title] shall apply in the case of notices sent to individuals after 1968. The provisions of subsections (e) and (f) [amending sections 1395f and 1395n of this title] shall apply in the case of services furnished (or deemed to have been furnished) after 1970."
WAIVER OF LIABILITY LIMITING RECOUPMENT IN CERTAIN CASES Pub. L. 101-239, title VI, §61096109,, 103 Stat. 2213, provided that: "In the case where more than the correct amount may have been paid to a physician or individual under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] with respect to services furnished during the period beginning on July 1, 1985, and ending on March 31, 1986, as a result of a carrier's establishing statewide fees for certain procedure codes while the carrier was in the process of implementing the national common procedure coding system of the Health Care Financing Administration, the provisions of section 1870(c) of the Social Security Act [42 U.S.C. 1395gg(c)] shall apply, without the need for affirmative action by such a physician or individual, so as to prevent any recoupment, or other decrease in subsequent payments, to the physician or individual. The previous sentence shall apply to claims for items and services which were reopened by carriers on or after July 31, 1987."
- Secretary
- The term "Secretary" means the Secretary of Housing and Urban Development.1See References in Text note below.
- person
- The term "person" means an individual, a trust or estate, a partnership, or a corporation.