Fillable Fsa Claim Form (Page 2 of 2) in pdf

PLEASE READ THIS BEFORE SUBMITTING YOUR CLAIM FORM

The Internal Revenue Code provides the following guidance:

UIDELINES

LAIMS

UBMISSION

Medical Reimbursement

The best receipt is an Explanation of Benefits from your insurance company.

•

If other receipts are submitted, they must show the following information:

•

1. Who rendered the service (name and address).

4. Amount of charge.

2. What type of service was rendered.

5. Any insurance payment, if applicable.

3. Date service was provided, not a billing or due date.

**Canceled checks and credit card slips are not allowable receipts.**

NOTE: In order to process your claim, all 5 pieces of information must be on each receipt.

(This includes receipts for orthodontic services.)

Any amount claimed which is a “Previous Balance” or “Balance Forward,” etc. cannot be paid unless the information stated

•

in items 1-5 above is shown on the receipt.

Receipts must show all expenses incurred. Any over-payment, pre-payment, etc., for which no services are listed, cannot be

•

reimbursed.

Over-the-Counter (OTC) drugs with doctor’s prescription and all other OTC items

Eligible Items

•

1. When and Who Sold the product (date, name, and address).

Subject to Change

See Current List at

2. Type of OTC purchased. Must show product or brand name.

3. Amount of charge.

NOTE: EVERY OTC DRUG CLAIM REQUIRES A COPY OF THE PRESCRIPTION TO BE ATTACHED.

If the receipt does not show the name of the product, you can write the product name on the receipt. You must have

the cashier verify by signing their name. **Canceled checks and credit card slips are not allowable receipts.**

Mileage Reimbursement

•

Mileage incurred to and from your home or office to receive medical care is reimbursable through the FSA at the rate

of $0.23 per mile. If rate has changed, amount will be adjusted at processing.

Mileage claim must include substantiation (i.e. provider invoice, receipt, etc.).

Dependent Care Reimbursement

Canceled checks are acceptable. Please include a copy of the front and back of the check, the dates of

•

service, and the facility federal ID number or the social security number of the individual providing service.

All receipts must show the following information:

•

1. Who rendered the service (name and address).

2. What type of service was rendered.

3. Date of original service, not a billing date.

4. Amount of charge.

5. Federal ID number (facility) or social security number (individual).

For Your Reference

Scheduled processing date(s): Weekly or Daily (company specific)

•

To ensure you are reimbursed, all claims must be received by BeneFLEX HR Resources, Inc. no later than

•

3:00 p.m. (central) 1:00 p.m. (pacific) Tuesday for weekly processing.

BeneFLEX phone numbers — (314) 909-6979 and (800) 631-3539 (outside St. Louis) or fax number (314) 909-6983.

•

If you terminate employment, any expenses incurred after your termination date are not eligible for reimbursement.

•

Medical Expenses can still be claimed if you continue your participation under COBRA.

If you fax your claim, keep a copy of the confirmation statement in case BeneFLEX does not receive your paperwork.

•

Please itemize the expenses on your claim form.

•

You can contact BeneFLEX HR Resources, Inc. by e-mail at or visit us online at

•

to review Frequently Asked Questions or download forms.

Check Your Account Balance

Visit us online at , click on “Employee” and then select “Employee Login.”

•

Download our mobile app, BeneFlexHR Mobile, (available on iTunes or Google Play).

•

Call our Interactive Voice Response System (IVR) at (855) 210-9527 and listen for the prompts.

•

BeneFLEX HR Resources, Inc.

10805 Sunset Office Drive, Suite 401 St. Louis, MO 63127 │ Email:

│Website:

09052014

Fsa Claim Form Page 2

Related Articles

Related forms

Related Categories