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 with an option code of “R,” “D,” “T,” or “W,” or cases with a current State buy-in on the MBR, or regular attainment cases (age
65 or disability cases) will be produced separately from the actual transfer cases,
and will contain the notation “No Letter-No Premium Liability.”
All output forms will be sent to the appropriate module for immediate handling. The
Records Analysis Clerk must staple the 5 ×8 informational forms to the matching Forms
HCFA-L623/623A where both types of output are received for the same claim number.
All 5 ×8 informationals, whether or not an HCFA-L623/623A is present, must be associated
with the claims folder and given to the Health Insurance and Inquiries Examiner for
For processed actions (i.e., only an HCFA-L623/623A is received) not requiring review
(see C. below), detach the letter portion, form HCFA-L623, and forward to the Mailroom
for release to the beneficiary. Prong-file the HCFA-L623A on the left-hand side of
the claims folder.
Do not mail letter portions bearing the notation “No Letter-No Premium Liability.” These forms must be detached and destroyed.