42 C.F.R. Subpart E—To Whom Payment is Made in Special Situations
Title 42 - Public Health
(a) This subpart sets forth provisions applicable to payment after the beneficiary's death and payment to entities that provide coverage complementary to Medicare Part B. (b) The provisions applicable to payment for services excluded as custodial care or services not reasonable and necessary are set forth in §§405.332 through 405.336 of this chapter. [53 FR 6634, Mar. 2, 1988, as amended at 53 FR 28388, July 28, 1988] (a) Scope. This section specifies the persons whom Medicare pays, and the conditions for payments, when the beneficiary has died and the bill has been paid. (b) Situation. (1) The beneficiary has received covered services for which he could receive direct payment under §424.53. (2) The beneficiary died without receiving Medicare payment. (3) The bill has been paid. (c) Persons whom Medicare pays. In the situation described in paragraph (b) of this section, Medicare pays the following persons in the specified circumstances: (1) The person or persons who, without a legal obligation to do so, paid for the services with their own funds, before or after the beneficiary's death. (2) The legal representative of the beneficiary's estate if the services were paid for by the beneficiary before he or she died, or with funds from the estate. (3) If the deceased beneficiary or his or her estate paid for the services and no legal representative of the estate has been appointed, the survivors, in the following order of priority: (i) The person found by SSA to be the surviving spouse, if he or she was either living in the same household with the deceased at the time of death, or was, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary; (ii) The child or children, who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child); (iii) The parent or parents, who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent); (iv) The person found by SSA to be the surviving spouse who was not living in the same household with the deceased at the time of death and was not, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary; (v) The child or children who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child); (vi) The parent or parents who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent). (4) If none of the listed relatives survive, no payment is made. (5) If the services were paid for by a person other than the deceased beneficiary, and that person died before payment was completed, Medicare does not pay that person's estate. Medicare pays a surviving relative of the deceased beneficiary in accordance with the priorities in paragraph (c)(3) of this section. If none of those relatives survive. Medicare pays the legal representative of the deceased beneficiary's estate. If there is no legal representative of the estate, no payment is made. (d) Amount of payment. The amount of payment is the amount due, including unnegotiated checks issued for the purpose of making direct payment to the beneficiary. (e) Conditions for payment. For payment to be made under this section— (1) The person who claims payment must meet the following requirements: (i) Submit a claim on a CMS-prescribed form and an itemized bill in accordance with the requirements of this subpart. (See paragraph (g) of this section for an exception.) (ii) Provide evidence that the services were furnished if the intermediary or carrier requests it. (iii) Provide evidence of payment of the bill and of the identity of the person who paid it. (2) If a person claims payment as the legal representative of the deceased beneficiary's estate, he or she must also submit a copy of the papers showing appointment as legal representative. (3) If a person claims payment as a survivor of the beneficiary, he or she must also submit evidence, if the intermediary or carrier requests it, that he or she is highest on the priority list of paragraph (c)(3) of this section. (f) Evidence of payment. Evidence of payment may be— (1) A receipted bill, or a properly completed “Report of Services” section of a claim form, showing who paid the bill; (2) A cancelled check; (3) A written statement from the provider or supplier or an authorized staff member; or (4) Other probative evidence. (g) Exception: Claim submitted before beneficiary died. If a claim and itemized bill has been submitted by or on behalf of the beneficiary before he or she died, submission of another claim form and itemized bill is not required; any written request by the person seeking payment is sufficient. (a) Scope. This section specifies whom Medicare pays, and the conditions for payment when the beneficiary has died and the bill has not been paid. (b) Situation. (1) The beneficiary has received covered Part B services furnished by a physician or other supplier. (2) The beneficiary died without making an assignment to the physician or other supplier or receiving Medicare payment. (3) The bill has not been paid. (c) To whom payment is made. In the situation described in paragraph (b) of this section, Medicare pays as follows: (1) Payment to the supplier. Medicare pays the physician or other supplier if he or she— (i) Files a claim on a CMS-prescribed form in accordance with the applicable requirements of this subpart; (ii) Upon request from the carrier, provides evidence that the services for which it claims payment were, in fact, furnished; and (iii) Agrees in writing to accept the reasonable charge as the full charge for the services. (2) Payment to a person who assumes legal obligation to pay for the services. If the physician or other supplier does not agree to accept the reasonable charge as full charge for the service, Medicare pays any person who submits to the carrier all of the following: (i) A statement indicating that he or she has assumed legal obligation to pay for the services. (ii) A claim on a CMS-prescribed form in accordance with the requirements of this subpart. (If a claim had been submitted by or on behalf of the beneficiary before he or she died, submission of another claim form is not required; a written request by the person seeking payment meets the requirement for a claim.) (iii) An itemized bill that identifies the claimant as the person to whom the physician or other supplier holds responsible for payment. (If such an itemized bill had been submitted by or on behalf of the beneficiary before he or she died, submission of another itemized bill is not required.) (iv) If the intermediary or carrier requests it, evidence that the services were actually furnished. [53 FR 6634, Mar. 2, 1988, as amended at 53 FR 28388, July 28, 1988] (a) Conditions for payment. Medicare may pay an entity for Part B services furnished by a physician or other supplier if the entity meets all of the following requirements: (1) Provides coverage of the service under a complementary health benefit plan (this is, the coverage that the plan provides is complementary to Medicare benefits and covers only the amount by which the Part B payment falls short of the approved charge for the service under the plan). (2) Has paid the person who provided the service an amount (including the amount payable under the Medicare program) that the person accepts as full payment. (3) Has the written authorization of the beneficiary (or of a person authorized to sign claims on his behalf under §424.36) to receive the Part B payment for the services for which the entity pays. (4) Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from the beneficiary, his or her survivors or estate. (5) Submits any information CMS or the carrier may request, including an itemized physician or supplier bill, in order to apply the requirements under the Medicare program. (6) Identifies and excludes from its requests for payment all services for which Medicare is the secondary payer. (b) Services paid for by the entity. An entity is not required to pay and claim reimbursement for all Part B services furnished to members of its plans. However, if it does not pay and claim reimbursement for all those services, it must establish in advance precise criteria for identifying the services for which it will pay and claim reimbursement. [53 FR 28388, July 28, 1988; 53 FR 40231, Oct. 14, 1988]
Title 42: Public Health
PART 424—CONDITIONS FOR MEDICARE PAYMENT
Subpart E—To Whom Payment is Made in Special Situations
§ 424.60 Scope.
§ 424.62 Payment after beneficiary's death: Bill has been paid.
§ 424.64 Payment after beneficiary's death: Bill has not been paid.
§ 424.66 Payment to entities that provide coverage complementary to Medicare Part B.
