Fillable Health Care Fsa Claim Form (Page 2 of 4) in pdf

Additional Health Care FSA Claims Information

Important Information

About Health Care Service Dates and Expense Reimbursement

IRS regulations place strict guidelines on reimbursements for Health Care expenses. One point of confusion in these

regulations is the difference between when an expense is paid versus when an expense is “incurred”. Per IRS regulations,

expenses reimbursed through a Health Care FSA are based on the date the expense was incurred, not the date you paid

for the service (with some exceptions). The date the expense was incurred is the actual date the services were provided

or, in the case of purchasing products, the date you purchased the products.

Orthodontia expenses are an exception because the service typically spans multiple plan years. Your payment contract for

the services will determine how you should submit the expenses on your FSA claims.

● Monthly/Weekly payments – Submit each payment as a separate expense along with the receipt showing the date of the

payment period and type of service.

● In Full – If you paid for the entire treatment in a single payment at the start of service, submit the contract along with the

plan of treatment and the amount paid with your claim form. Note: Even if the treatment is spread over 2 years, the

entire amount will come out of your current plan year account.

When you have a large number of receipts to submit, you have the option of sending the details of your claims on a

spreadsheet showing the date, provider, amount and type of service for each item. For the type of service, you should

categorize your expenses as RX (for prescription), over-the-counter, co-pay, etc. The spreadsheet should then be

submitted with your completed claim form(s) and receipts.

Filing Multiple Expenses with the Same Service Date and Same Amounts

There may be times when you need to submit multiple expenses for the same amounts that were incurred on the same

date. For example, you have two children who are both ill. Both children see the doctor on the same day and both

children receive their own prescription with the same co-pay amount. The ADP claims processing system automatically

categorizes claims based on the service date and amount and then compares those dates and amounts to claims you

have already submitted. By filing a separate claim form for each child, the claim that is received and processed second

will be marked as a duplicate claim. When submitting multiple claims with identical service dates and amounts, you should

submit these expenses on the same claim form whenever possible. If the claims are for eligible dependents, be sure to

include the dependent name and date of birth where indicated. This will help prevent eligible expenses from being

inadvertently marked as duplicate claims.

You will receive a notification when a claim is marked as a duplicate. In the event a claim is mistakenly considered a

duplicate, please contact your Participant Solution Center to have the claim status corrected. You can review your claims

online at

Resubmitting an FSA Claim When Additional Information is Requested

On occasion, you may be asked to resubmit a claim because information you provided was insufficient. You may have

neglected to provide required information such as an itemized receipt or perhaps you just forgot to sign the claim form. In

the event you are asked to resubmit a claim, you must submit a new claim form with the requested information.

Depending on the situation, it may not be necessary to resubmit the entire claim. For example, if you filed a claim with four

purchases and only one purchase required additional information, you would file a new claim for that one purchase

with its supporting documentation. You should not resubmit the entire claim with all four purchases as this will result in

duplicating the other three purchases and you would receive a letter indicating that these purchases had been duplicated.

However, if you forgot to include receipts or if you neglected to sign your claim form, it would be necessary to

resubmit the entire claim with all its supporting documentation.

For questions or additional information on resubmitting claims, please contact your Participant Solution Center or visit

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Health Care Fsa Claim Form Page 2