Health Flexible Spending Account (Fsa) Reimbursement Request Page 2
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2FILING A CLAIM
Please read these important reminders for quick and efficient reimbursement:
Please make sure to fill out your form completely (employer, ID#, your name).
Documentation must include service dates, service description and charges for
services received.
Combine all like reimbursement requests. For example, If you are submitting
several prescription receipts for reimbursement, enter the range of dates over
which the purchases were made and the total of all the receipts on the
prescription line:
Prescription Reimbursement Request
From: 7/1/12
To: 7/31/12
$145.78
Service dates must be within the plan year to be eligible expenses. If your
employment terminates during the plan year, service dates must be within the
plan year and while you were an active participant in the plan (ie: eligible and
making contributions).
If the service is eligible for insurance, an explanation of benefits must
accompany the claim form, unless the bill from the provider shows the amount
that insurance has paid, or the receipt is clearly a co-pay amount. Bills from
providers that estimate insurance payment will not be reimbursed.
If the reimbursement requested is not eligible for submission to insurance for
reimbursement consideration, a bill or receipt showing date, service and
charges is adequate documentation of the expense, as long as there is no
reference to insurance coverage on the bill or receipt.
Eligible claims received must total at least $1.00 before a check will be mailed
or an electronic deposit initiated by Allegiance.
Save time! Direct deposit is a convenient and easy way to receive your flex
reimbursement- see
and sign up today!
6/12
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