
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395gg]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 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.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1870, as added Pub. L. 89-97, 
title I, Sec. 102(a), July 30, 1965, 79 Stat. 331; amended Pub. L. 90-
248, title I, Sec. 154(b), (c), Jan. 2, 1968, 81 Stat. 862; Pub. L. 92-
603, title II, Secs. 261(a), 266, 281(a), (b), Oct. 30, 1972, 86 Stat. 
1448, 1450, 1454, 1455; Pub. L. 93-445, title III, Sec. 309, Oct. 16, 
1974, 88 Stat. 1358; Pub. L. 96-499, title IX, Sec. 954(a), Dec. 5, 
1980, 94 Stat. 2647; Pub. L. 97-248, title I, Sec. 128(d)(1), Sept. 3, 
1982, 96 Stat. 367; Pub. L. 100-203, title IV, Secs. 4039(h)(7), 
4096(a)(2), Dec, 22, 1987, 101 Stat. 1330-139, as amended Pub. L. 100-
360, title IV, Sec. 411(e)(3), July 1, 1988, 102 Stat. 776; Pub. L. 100-
360, title IV, Sec. 411(j)(4)(B), July 1, 1988, 102 Stat. 791.)

                       References in Text

    The 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, Sec. 101, Oct. 16, 1974, 88 Stat. 1305, which is classified 
generally to subchapter IV (Sec. 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.


                               Amendments

    1988--Pub. L. 100-360, Sec. 411(e)(3), added Pub. L. 100-203, 
Sec. 4039(h)(7), see 1987 Amendment note below.
    Subsec. (f)(1), (2). Pub. L. 100-360, Sec. 411(j)(4)(B), substituted 
``of assignment specified in'' for ``specified in subclauses (I) and 
(II) of''.
    1987--Pub. L. 100-203, Sec. 4039(h)(7), as added by Pub. L. 100-360, 
Sec. 411(e)(3), amended section catchline generally.
    Subsec. (f)(1), (2). Pub. L. 100-203, Sec. 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, Sec. 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, Secs. 261(a), 281(b), 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) of this section, 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, Sec. 266, added subsec. (g).
    1968--Pub. L. 90-248, Sec. 154(b), provided for settlement of claims 
for benefits on behalf of deceased individuals in section catchline.
    Subsecs. (e), (f). Pub. L. 90-248, Sec. 154(c), added subsecs. (e) 
and (f).


                    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

    Section 954(b) of Pub. L. 96-499 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

    Section 261(b) of Pub. L. 92-603 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].''
    Section 281(g) of Pub. L. 92-603 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, Sec. 6109, Dec. 19, 1989, 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 [part B of this subchapter] 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 [subsec. (c) of this section] 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.''

                  Section Referred to in Other Sections

    This section is referred to in sections 1395i, 1395t, 1395u of this 
title; title 2 section 906.
