HI 01001.135 Processed Actions

HCFA-L623A is generated by the JURIS program and filed in the claims folder when a notice of jurisdiction has been received from RRB. The letter portion, HCFA-L623, is released to the beneficiary as notification of RRB jurisdiction of HI and SMI coverage only in situations where SSA had previously established SMI coverage based on an enrollment. If the individual's option is “R,” “T,” “W,” or “D,” or there is a current State buy-in (third party code 010-650) on the MBR, the notice will be produced, but will not be mailed. The HCFA-L623A represents the effectuation of HI and SMI jurisdiction transfer to RRB; the computer process has updated the MBR and HIM records to reflect the appropriate jurisdiction. At the time of processing, the current premium due amount had been transmitted to RRB with the response to their input, and any appropriate trust funding has been accomplished.

A. Explanation of Specific Items Contained on HCFA-L623/623A's

HCFA-L623/623A is titled “Notice/Record Regarding Collection of Medicare Premiums.” The two-part “side by side” form serves as documentation to be filed on the left side of the claims folder (HCFA-L623A) and notification to be released to the beneficiary (HCFA-L623).


This entry contains the date the form was processed through the program service center print program.


The claim number is the CAN/BIC for the individual involved. Where a combined check is involved (AB), both BIC's are printed.


The name and address, as it appears in SSA records, will be printed here.


The folder location indicator will be displayed.

5. RUN NO.

The date of the computer run is indicated as the run number. For example, a run processed on March 15 is shown as “315.” Entries for October, November, and December are shown as “0,” “X,” and “R,” respectively.


This is the month the data shown on the form will update to the regular transcript.


These four-digit entries represent the action block number against which the action is processing and the newly assigned action block number established by the JURIS program.


Date-This month and year entry represents the effective date of the credit generated by the JURIS program.

Amount-The amount of the monthly benefit check being stopped is shown; e.g., if the monthly payment amount was $200.00 after SMI premiums were being deducted, the amount shown is $200.00.

CMA-AMT-This represents the amount of the monthly payment after the RRB transfer has applied. If the old monthly payment amount had been $100.00 and the SMI premium was $7.20, this block would reflect $107.20.

NOTE: When the beneficiary is in suspended or deferred payment status, or is an uninsured claimant, these items will be blank.

9. BIC

The BIC of the beneficiary whose HI/SMI status is being transferred is shown.

10. MBA

The current monthly benefit amount is indicated for all insured beneficiaries. The block is blank for uninsured individuals. For PIC “O” cases, the data for both beneficiaries is shown.

11. MBP

The new monthly benefit payable is shown for each beneficiary symbol shown in the BIC column.


This block will contain the RRB annuity number for all transfer cases. This number, which has a one-, two-, or three-position alphabetic prefix symbol, must be used whenever it is necessary to communicate additional information to RRB or to the Office of Central Records Operations (OCRO) (see HI 01001.140 and HI 01001.145 below for alert and exception processing). This block will also show the SOBER Operating Month (SOM) used in notifying RRB of the current premium due amount (PDA) status.

There are sometimes instances when a “double deduction” situation occurs; i.e., both RRB and SSA are collecting premiums from the same individual. When these cases are processed by JURIS, the excess premiums will be refunded to the individual in a separate check by the JURIS program. These cases are recognizable by the presence of specific statements appearing on the computer output. The HCFA-L623 will reflect, “Any excess premiums you have paid will be refunded to you in a separate check.” The HCFA-623A will contain the statement, “PMA REFUND AMT$” which will appear above the second line of entries.

B. Receipt and Handling of Output

The two-part HCFA-L623/623A will be produced for each case processed, representing a transfer of jurisdiction of HI and/or SMI maintenance to RRB.

For a combined check case (PIC “0”), one form will be printed. The output for cases wi