Form Cl-472 - Request For Reimbursement Preferred Health Fsa/hra - Blue Cross Blue Shield Of Alabama Page 2

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Helpful Tips for Successfully Filing a Request for Reimbursement.
1.
Complete your Request for Reimbursement Form neatly.
If your form can not be read properly, it cannot be processed accurately.
• Do not highlight receipt items. Circle them instead.
(High-lighter when faxed or scanned can appear as black or gray)
• Only submit expenses for an eligible dependent. An eligible dependent must meet the provisions
of sections 105 and 106 of the U. S. Internal Revenue Code.
2.
Provide appropriate supporting documentation.
IRS rules state that you must provide appropriate documentation.
• Documentation for an eligible healthcare expense must show:
The date of service (the date you incurred the expense)
The name of the service provider
To whom the service was provided (patient’s name)
The out of pocket expense (amount you paid for the service)
A clear and detailed service/procedure description
• Documentation for an eligible premium payment must show:
The name and address of the company to whom the premium payment was made
The policy number of your insurance
A list of those covered under the policy
The date of the premium payment
The time period the premium payment covered
What is acceptable documentation?
Examples of proper documentation are:
• An Explanation of Benefits (EOB) from your insurance carrier showing the above information.
If the EOB indicates the procedure is not covered by your health insurance plan, you may be
required to submit an itemized statement from the provider.
• For premium payments, a premium notice with proof of payment or check stub showing the
premium deduction.
• For prescription drugs, a pharmacy statement including the name of the pharmacy, patient’s name,
date the RX was filed, patient’s cost, RX number and name of the drug.
• Over-the-counter (OTC) medications and other “dual purpose” items will not be reimbursed without
a written doctor’s prescription. You must also include an itemized receipt indicating the item purchased.
Unacceptable documentation for healthcare expenses:
Bank card statements, credit card receipts, canceled checks, estimates of expenses, account balance
statements and balance forward statements are not valid documentation.
3.
Sign your form.
An unsigned form will stop your reimbursement!
4.
Submit your form.
Completed forms can be submitted on our website at , with the Alabama Blue mobile app
on your smart phone, by mail, or by fax to our toll-free number.
CL-472 (Rev. 11-2014)

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