HOW TO FILE A CLAIM FOR FLEXIBLE SPENDING



HOW TO FILE A FLEXIBLE SPENDING CLAIM FOR HEALTHCARE REIMBURSEMENT

|Qualification Criteria: |Examples include: |In addition to the completed, signed and dated claim |

| | |form you need to submit |

|If the expense is covered |Medical and dental expenses must be submitted to your medical or dental plan first. |An Explanation of Benefits (EOB) stating the name of|

|by any insurance |Health plan co-payments do not require an EOB, if you submit a receipt from your |the provider, the name of the patient, date/s of |

| |health care provider for the amount and indicate “co-payment” on the Claim Form. |service, a description of the service performed, the |

| | |amount that insurance is paying towards the bill, and|

| | |the amount that is patient responsibility |

|If the expense is not |Acupuncture, Childbirth classes (for the mother only), Contact Lenses, Eyeglasses, |A statement from the provider of the service clearly |

|covered by insurance |LASIK, medical aids, medical information plans, Mental health services that are |stating the provider’s name, address and phone |

| |covered under your health plan, but you choose to pay out of pocket without |number, the name of the patient, date/s of service, a|

| |submitting to your health care plan, certain infertility treatments * Please note |description of the service performed, and the amount |

| |this is not an exhaustive list of what may be reimbursable |that is patient responsibility. |

|Prescriptions | Prescriptions that are covered by your insurance. |A copy of the prescription receipt that indicates the|

| | |name and address of the pharmacy, the name of the |

| | |prescription, the date of purchase, and the patients |

| | |out of pocket responsibility. |

|Over the counter drugs |Acne Treatment, Allergy Prevention and Treatment, Analgesics, Antipyretics, Antacids,|An itemized receipt indicating the name and address |

|(OTC) |Acid Reducers, Anti-arthritics, Anticandial (yeast), Antidiarrheal, Anti-fungal, |of the provider, the date of purchase, the name of |

| |Antihistamines, Anti-itch Lotions and creams, Asthma Medicines, Cold Sore/Fever |the product, and the cost. If your receipt does not |

| |Blister, Cold, Flu, Decongestant, Sinus, Contact Lens Supplies, Contraceptive/Family |have all of this information you must submit a copy |

| |Planning supplies, Cough Suppressants, Dehydration, Denture Care, Diaper Rash, Ear |of the label with a dated receipt. If you are |

| |Care, Eye Care, First Aid/Medical Supplies, Foot Care, Hand Sanitizers, Headache/pain|submitting a bill for an over the counter item that |

| |relief, Hermorrhoidal Preparations, Home Diagnostic Tests or Kits, Lactose |is potentially eligible (e.g. vitamins) you must |

| |Intolerance Supplements, Medicated Lip Products, Migraine Relief, Motion Sickness, |submit a Letter of Medical Necessity (LMN) from your|

| |Nasal Strips and Topical Antibiotics, Sunscreen, Smoking Cessation, Wart removal, |doctor. |

| |Lice Removal, Sleeping Aids, and Topical Steroids | |

| |*Please note that this list is not exhaustive of all eligible OTC items. | |

In general you may be reimbursed for a Healthcare expense, which qualifies as a deduction on federal income tax returns. Also, the expense must not be reimbursed by any other source and must not be deducted on your income tax return. For more information about eligible expense you should refer to I.R.S. Publication 502.

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