Form 6518 (W0407) - Claim For Reimbursement - Horizon Blue Cross Blue Shield (Page 2 of 2) in pdf

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CLAIM FILING INSTRUCTIONS

Who files a claim form?

• Only employees participating in the company Flexible Spending Account Plan can file a reimbursement claim form.

• Employees can file a claim for during the plan year and for a certain period after the plan year as described in the Summary

Plan Description.

• Terminated employees can file a claim form for a certain period after the date of termination if allowed by the plan.

Please see your Summary Plan Description.

Which expenses can I claim?

• You can claim only expenses incurred during the plan year for reimbursement. Each year is treated separately and the year of

claim is the year the expense was actually incurred by the participant. You must send separate claim forms for each year.

• Terminated employees can request reimbursement for expenses incurred during the time period for which contributions were

received. Please see your Summary Plan Description.

• Allowable expenses are the same as those allowed for tax purposes. See the summary below.

Qualifying dependent care expenses

• Expenses paid to a dependent day care center or care provider.

• Expenses paid for the care of a dependent under age 13.

• Expenses paid for care of other dependent(s) who are physically or mentally incapable of caring for themselves.

Qualifying unreimbursed medical expenses

• You can only claim expenses not reimbursed by insurance, including:

Ambulance hire

Blood donor

Hospital bills

Oral surgery

Rental of

Telephone for deaf

Artificial limbs/teeth

Chiropractor

LASIK eye surgery

Osteopath

medical/healing

Television set

Automobile modifications

Christian Science

Lip reading lessons

Oxygen equipment

equipment

modifications to

(hand controls/special

practitioners

for the deaf

Pediatrician

Retirement home

receive closed

equipment/mechanical

Clinic

Medical

Physician

fees, portion

captions

lifts)

Dentist (excluding

Midwife

Physiotherapist

allocable to

Therapy treatments

Braille books/magazines

cosmetic services,

Nurse

Podiatrist

medical care

Transportation

Crutches

i.e., teeth whitening)

Obstetrician

Practical nurse

Seeing eye dog

expense relative to

Elastic hose, medically

Diagnosis

Obstetrical expense

Prescription drugs and

Sex therapist

illness

prescribed

Diathermy

Oculist

medical supplies

Special education

X-rays

Eyeglasses/contact

Exam, physical

Operations/related

excluding cosmetic Rx

Specialist

Wheelchair

lenses/solutions

Gynecologist

treatments

Psychiatrist

Supportive/corrective

Eye exam

Halfway house

Ophthalmologist

Psychoanalyst

devices (including

Fees

residency

Optician

Psychologist

special mattress/

Acupuncture

Healing services

Optometrist

Psychopathist

board for arthritis)

Anesthetist

Hearing devices

Surgeon

Completing the claim form

• Complete all information on the claim form for each amount claimed for reimbursement.

• Make sure the claim does not include items for more than one plan year. Use different claim forms for different years.

• You must sign and date the claim form.

• Attach copies of bills, invoices or other written statements from a third party that support each reimbursement request and mail

or fax to:

H Horizon Blue Cross Blue Shield of New Jersey

Fax: 973-274-2215

Three Penn Plaza East PP-05S

Web site:

Newark, NJ 07105-2200

Form 6518 (W0407) - Claim For Reimbursement - Horizon Blue Cross Blue Shield Page 2

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