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

Claim Form Instructions

Complete employee information section. Be sure to write legibly to ensure proper processing.

Itemize your expenses in the table provided and attach copies of your documentation.

Documentation must clearly show the date of service, type of service, and final cost of service. Examples of acceptable

documentation include itemized bills/invoices, or the Explanation of Benefits (EOB) from your insurance carrier.

If your employer offers an HRA and you are enrolled in a plan that only offers reimbursement for deductible,



coinsurance, and/or copays an EOB is required for claim submission.

If the expense is a copay amount (multiple of $5 up to $500), a payment receipt is acceptable documentation.



Proof of payment is not required in order to reimburse medical/dental/vision services.

Prescriptions

Examples of acceptable documentation include the Rx label, payment receipt, or mail order statement showing the date

filled, Rx name or Rx #, and cost. You may also submit an itemized printout from your pharmacy.

OTC Medications & Drugs

Per IRS regulations, OTC medications and drugs with an active ingredient must be accompanied by a prescription in order to

be reimbursed from your FSA (ex. pain relievers, cold/allergy medication, ointments, Antacids). Once approved, prescriptions

will remain on file with Navia for future claim submissions. Prescriptions are valid for one year after the date written.

Alternative Treatments

Expenses that may be seen as merely beneficial to general health will require a Letter of Medical Necessity (LMN), showing

the treatment of a specified medical diagnosis. Examples include vitamins/supplements, herbs, weight loss programs,

cosmetic products and procedures. Please have your provider write a letter or complete our

Letter of Medical Necessity

template.

Dependent Care

Acceptable documentation includes an itemized bill/invoice, showing the date of service, type of service, and cost of service.

If the dependent is age 5 or older, the documentation must show the services are “for care,” and not educational in nature.

If you are unable to obtain sufficient documentation, you may have the provider sign the front of this claim form to validate

the services being claimed.

If you would like to automate your recurring daycare expenses, you may do so by completing our

Recurring Daycare Claim

Form, logging onto our Participant Portal, and selecting the My Recurring Claims tool tile.

Please DO NOT submit the following types of documentation:

Statements showing estimated/pending insurance



Statements showing the claimed amount as a balance forward/previous balance



Statements showing the claimed amount as a prepayment for future services



Cancelled checks/copies of cashed checks



Personal bank statements



Be sure to sign the claim form and submit! Please fax, email or mail a signed claim form, but choose one method only.

General Claims Submittal:

Email:

Fax:

Local (425) 451-7009 or Toll-free (866) 535-9227

Mail:

Navia Benefit Solutions

PO Box 53250 Bellevue, WA 98015

Phone: Local (425) 452-3500 or Toll-free (800) 669-3539

If your employer offers an HRA, Dental or Wellness plan, submit to:

Email:

Fax:

Local (425) 709-7125 or Toll-free (866) 831-6222

Mail:

Navia Benefit Solutions

PO Box 53250 Bellevue, WA 98015

Phone: Local (425) 452-3421-3500 or Toll-free (866) 897-1996

Claims status is available online. Please allow at least two (2) full business days for Navia to process your claim.

REV 9/18/2015

Claim Form Navia Page 2

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