TN 12 (01-14)

RS 01602.626 Form RR-80 Report of Health Insurance (HI) Information with SSA Jurisdiction

This form is used by the RRB to transfer Medicare jurisdiction to SSA.

A. RRB transfers HI jurisdiction to SSA

Follow these instructions if the RRB transfers HI jurisdiction to us.

IF…

THEN…

You receive Form RR-80 from the RRB.

Follow HI 01001.150, and

Clear the control when you take the required PC action.

Inform the beneficiary by a special notice that we will issue benefit notices about Medicare entitlement rather than the RRB.

You identify a post-entitlement event that causes a change in certification responsibility.

Contact the RRB to obtain an RR-80 and follow the above procedures.

Dates of entitlement to Medicare based on form RR-3 differs from dates shown on the RR-80

Contact the RRB to determine which date is correct and request a revised RR-80, if necessary.

B. Exhibit of Form RR-80 – RRB Report of Health Insurance Information SSA Jurisdiction

RRB Report of Health Insurance Information SSA Jurisdiction

 View PDF Version

C. Exhibit of Form RR-3T – SSA Jurisdiction of Survivor Benefits, RRB Report of Events Affecting SSA Payments and Medicare Information

This form is used by the RRB to report events to SSA

SSA Jurisdiction of Survivor Benefits RRB Report of Events Affecting SS Payments and Medicare Information

 View PDF Version


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0301602626
RS 01602.626 - Form RR-80 Report of Health Insurance (HI) Information with SSA Jurisdiction - 01/28/2014
Batch run: 01/28/2014
Rev:01/28/2014