2014 Hcsa Reimbursement Request Form With Instructions Page 2
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1
2HEALTH CARE SPENDING ACCOUNT
INSTRUCTIONS FOR REIMBURSEMENT
General Instructions:
Period of Coverage:
Make sure you complete Section B in its entirety.
Reimbursement can only be made for expenses resulting from medically necessary
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services that have been provided within your period of coverage. Your period of
Reimbursement cannot be claimed if the cost has been or can be reimbursed under
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coverage is January 1 through December 31 if you enroll during the open enrollment
any other source.
period. If you enroll during the Plan Year as a new hire, your period of coverage begins
Services must have been incurred to receive reimbursement. You may not request
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on the 61
st
consecutive calendar day of your employment. If you enroll during the Plan
reimbursement until you have received the service, regardless of when you pay for it.
Year due to a change in status, your period of coverage will be based on the date your
The expenses for which you receive reimbursement cannot be claimed on your
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CIS request is received by the Plan. If you terminate employment or take an unpaid
income tax return.
leave of absence during the Plan Year, your period of coverage will end once you leave
According to IRS regulation, any unused year-end balance in your spending account
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the payroll and stop contributing to your account.
may not be carried over to the next Plan Year. It will be forfeited to New York State
If a service is provided during your current period of coverage and will continue to be
as your employer.
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provided in a subsequent Plan Year, you will not receive reimbursement for the
Be sure to sign and date this form, after reading it carefully. Mail or fax the completed
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services you receive in that subsequent Plan Year unless you re-enroll in the
form to FBWW and keep a copy for your records.
HCSAccount and submit a reimbursement request form for that period of coverage.
You may access your account information or obtain reimbursement request forms 24
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For services that require a letter of medical need, a new letter from your health care
hours each day by visiting or calling FBWW’s toll-free Interactive
provider indicating the services are medically necessary must be submitted with the
Benefits Information Line at 1-800-865-3262.
request for reimbursement in the subsequent Plan Year.
The standard mileage rate reimbursable for use of an automobile to obtain medical
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If dates of service begin in one Plan Year and end in the next Plan Year, and you are
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care is subject to change by the IRS annually. Visit the Flex Spending Account
enrolled for both years, please prorate the expenses and complete a separate form for
website at for the current rate. Your request for mileage
each Plan Year.
reimbursement must include documentation (such as a receipt from a doctor’s office)
New York State allows for a 90-day runout period after the end of your Plan Year during
to verify that the travel is related to medically necessary treatment.
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which you may submit reimbursement requests for services that were received during
Documentation Instructions:
your period of coverage.
To request health care expense reimbursement, a copy of your statement, bill or receipt
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from your health care service provider(s) showing the services received must be attached
to this form. This statement must clearly identify the patient’s name, service provider’s
name and address, date and type of service provided, and amount of expense. For
MAIL FORM TO:
reimbursement of prescription drug costs, your receipt must also include the prescription
name and number. OTC drugs require a written prescription in order to be reimbursed.
Fringe Benefits Management Company, a Division of WageWorks
At the beginning of the Plan Year in which you seek reimbursement for orthodontia
Post Office Box 1820
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expenses, you must submit a copy of the service contract between you and the orthodontist
Tallahassee, Florida 32302-1820
describing the payment arrangement/schedule.
Customer Service: (800) 358-7202 (option 1)
Copies of cancelled checks or charge card receipts are not sufficient documentation of
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incurred expenses.
OR…
Submit legible photocopies of your original statements, bills or receipts, and retain the
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originals for your records. Do not highlight any portion of the receipts or statements, as it
FAX FORM TO: (800) 743-3271
may make the documents illegible and result in your claim being rejected.
Expenses for cosmetic services and procedures, and items that have a personal, living or
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OR…
family use are ineligible for reimbursement through the HCSAccount. The health care
services must promote the proper function of the body or must be designed to treat,
SUBMIT FORM ONLINE AT:
prevent, cure or mitigate a specific medical condition as defined by IRS regulations. A letter
from your health care provider indicating the services are medically necessary must be
If you either fax your reimbursement request form to FBWW or submit it
submitted with the request for reimbursement of services that are generally considered
online, do not mail the form as well.
cosmetic, personal, living or family in nature.
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