Page:United States Statutes at Large Volume 86.djvu/1427

 86 STAT. ]

PUBLIC LAW 92-603-OCT. 30, 1972

1385

" L T M I T A T I O X O X L I A B I L I T Y O F BENErlCIARY WHERE MEDICARE CLAIMS ARE DISALLOWED

"SEC. 1879. (a) Where— "(1) a determination is made that, by reason of section 1862(a) (1) or (9), payment may not be made under part A or part B 42 USC i395y. of this title for any expenses incurred for items or services fur- 42 USC 1395c, nished an individual by a provider of services or by another per- Json pursuant to an assignment under section 1842(b)(3)(B) (ii), ^"'«'' P- I384. and "(2) both such individual and such provider of services or such other person, as the case may be, did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B, then to the extent permitted by this title, payment shall, notwithstanding such determination, be made for such items or services (and for such period of time as the Secretary finds will carry out the objectives of this title), as though section 1862(a)(1) and section 1862(a)(9) did not apply. I n each such case the Secretary shall notify both such individual and such provider of services or such other person, as the case may be, of the conditions under which payment for such items or services was made and in the case of comparable situations arising thereafter with respect to such individual or such provider or such other person, each shall, by reason of such notice (or similar notices provided before the enactment of this section), be deemed to have knowledge that payment cannot be made for such items or services or reasonably comparable items or services. "(b) In any case in which the provisions of paragraphs (1) and (2) of subsection (a) are met, except that such provider or such other person, as the case may be, knew, or could be expected to know, that payment for such services or items could not be made under such l)art A or part B, then the Secretary shall, upon proper application filed within such time as may be prescribed in regulations, indemnify the individual (referred to in such paragraphs), subject to the deductible and coinsurance provisions of this title, for any payments received from such individual by such provider or such other person, as the case may be, for such items or sendees. Any payments made by the Secretary as indemnification shall be deemed to have been made to such provider or such other person, as the case may be, and shall be treated as overpayments, recoverable from such provider or such other person, as the case may be, under applicable provisions of law. I n each such case the Secretary shall notify such individual of the conditions under which indemnification is made and in the case of com]>arable situations arising thereafter with respect to such individual, he shall, by reason of such notice (or similar notices provided before the enactment of this section), be deemed to have knowledge that payment cannot be made for such items or services. "(c) No payments shall be made under this title in any cases in which the provisions of paragraph (1) of subsection (a) are met, but both the individual to whom the items or services were furnished and the provider of service or other person, as the case may be, who furnished the items or services knew, or could reasonably have been expected to know, that payment could not be made for items or services under part A or part B by reason of section 1862(a)(1) or (a)(9). " (d) In any case arising under subsection (b) (but without regard to whether payments have been made by the individual to the provider or other person) or subsection (c), the provider or other person shall have the same rights that an individual has under section 1869(b) Post, p. i464. (when the determination is under part A) or section 1842(b)(3)(C) ^°®'' P* ^'*'*^-

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