Flexible Spending Accounts Claims Guidebook

Transcription

1 Flexible Spending Accounts Claims Guidebook Revised Fall Reynolda Road Winston-Salem, NC (336) (888) Fax (877)

2 How to Use Your Flexible Spending Account As a Third Party Administrator, one of our primary functions is timely, efficient processing of reimbursement claims for Medical/Dental/Vision and Dependent Care FSAs. By following the guidelines included in this publication, referring to our website at and contacting ProBenefits with any remaining questions, you will assure yourself that your claim will be processed and your reimbursement received as quickly as possible. What are reimbursable expenses under the Medical/Dental/Vision Care FSA? In order to be eligible for reimbursement, an expense must meet several criteria: 1. The expense must meet IRS guidelines for expenses considered to be primarily for medical care. Our web site provides a detailed, if not exhaustive, list of reimbursable medical expenses at 2. The expense must be incurred by the participant or the participant s eligible dependents. 3. The expense must not be reimbursed by insurance or any other benefit plan. 4. Reimbursement is based on the date of service, not the date of payment (except in the case of orthodontia see below), so the expense must have been incurred during the plan year and while you were an eligible participant in the plan. What are reimbursable expenses under the Dependent Care FSA? Dependent care expenses must be incurred so that you and your spouse (if applicable) can work, look for work, or attend school full-time. Covered eligible expenses must be for: Dependent children age 12 and under; and/or A person of any age whom you claim as a dependent on your taxes, and who is mentally or physically incapable of caring for himself or herself. Eligible expenses include: Childcare (nursery, preschool or private sitter) Before- and after-school care Day camps Ineligible expenses include: Kindergarten tuition Overnight camps Expenses paid to a tax-dependent Expenses not directly related to actual care What Constitutes a Valid Claim? All claims must contain the following: Properly completed Reimbursement Claim Form Supporting documentation indicating the service provider, the date(s) services were rendered, and the out-of-pocket expense for those services. What Constitutes a Properly Completed Reimbursement Claim Form? The following information must be supplied by the participant: Participant name Employer

3 Date(s) of Service The dates of service supplied on the Reimbursement Claim Form may be a single date for one receipt or a range of dates for multiple receipts. A range of dates begins with the earliest date of service and ends with the latest date of service. Payment for services rendered is not relevant. It must be documented that the service was actually rendered during the plan year. Amount This represents the total amount the participant is requesting for reimbursement based on the included documentation. Signature What Constitutes Valid Documentation? A good rule of thumb is that documentation must clearly show the provider name, the date of service, enough about the type of service provided that eligibility of the expense can be fully evaluated, and the amount of expense that is the participant s responsibility (not covered by insurance or any other plan). Also, for medical claims, documentation must come from the provider or insurance company. For Dependent Care only, the participant may prepare a document with the required information and have the caregiver sign it. Valid types of supporting documentation for a Medical/Dental/Vision FSA include: Statement from a medical practice An Explanation of Benefits (EOB) statement from the insurance company An itemized cash register receipt designating Rx and/or eligible over-the-counter items Prescription label Account summary provided by a medical practice or pharmacy Invoices that show the date of service (payment and/or statement dates are irrelevant), the medical provider, and the amount charged to the patient Valid supporting documentation for a Dependent Care FSA must include: Name of the Caregiver Tax ID/Social Security # of the Caregiver Date(s) of service Amount charged What Constitutes Invalid Documentation? Credit card receipts Debit card receipts Cancelled checks Bank statements A list of expenses supplied by the participant Any of the documents listed under Valid Documentation that does not contain the required data; that is, the provider, date and type of service and the out-of-pocket expense How Are Claims Received? Claims are received by fax, , or mail. All claims are processed within one to two business days after we receive them. Whether received electronically or by mail, all claims are examined for validity, entered in our database, and saved for future reference.

4 To submit your claim via toll-free fax: Fax claim form and documentation to: o Direct Deposit: Fax-a-Claim 866-FAX-FLEX (that's ) o Check-by-Mail: Fax-a-Claim 877-FAX-FLEX (that's ) To submit your claim by Make a clear scan of your signed claim form and supporting documentation. o Save in PDF or TIFF format (other file formats may not be accepted, or may result in processing delays) o to Flex@ProBenefits.com To submit your claim by mail: Make a good, clear copy of your claim form and all documentation to send to ProBenefits, and keep your originals on file in case of lost mail. Mail to: ProBenefits, Inc Reynolda Road Winston-Salem, NC Is Orthodontia Processed Differently? Yes. For orthodontia prepayments only, the IRS will consider the date of payment as the date of service. This means that if you pay your portion of the expense in full at the beginning of your orthodontia treatment, you can be reimbursed right away for the full amount of your payment up to the amount available in your election, even though the full treatment may extend across multiple plan years. If you are making payments toward your orthodontia treatment, you can be reimbursed each time you make a payment. For more important details on the reimbursement of orthodontia expenses and the documentation requirements for filing an orthodontia claim, please visit our website: How will I know if you received my claim? Your claim will be processed within 1-2 business days after receipt by ProBenefits. The morning after your claim is processed, you will receive an ed confirmation notifying you that we have entered your claim and letting you know of any problems. You can also check online at to see an image of your claim, with any problem areas noted. You can log in to your account online at to make sure we have the correct address to send your confirmation. If we have no address on file, you will receive a letter by mail if there are any problems with your claim. You will still be able to view your claim status online, even if we don't have an address. What is the appeal process for denied claims? The notification you will receive after your claim is processed will detail any issues with the claim and will give instructions on how to remedy the problem. Missing or inadequate information must be supplied with a properly completed Reimbursement Claim Form. After reading the notice and viewing your claim image online, please contact ProBenefits if you still have questions.

5 How long after the end of the plan year may claims be submitted for services rendered during that year? Claims may be submitted up to 90 days after the end of the plan year. For example, March 31 would be the last day to submit claims for the plan year ending December 31. If you terminate your participation in the plan at any time during the year, due to a change of status or termination of employment with the sponsoring company, you have 90 days after termination of participation to submit your claims. Are there different options available for how reimbursement is made? Consult your Benefits Administrator to determine if your employer offers check reimbursement and/or direct deposit. How often are reimbursements made and on what schedule? For monthly check reimbursement, the rule that governs reimbursement is in by the 5 th, out on the 15 th. This means that if your claim is received in our office by midnight on the 5 th of the month, your check will be mailed from our office on the 15 th of the month (or the last business day preceding the 15 th if that date falls on a weekend or holiday). For weekly direct deposit, the rule that governs reimbursement is in by Friday, out on Wednesday. If your claim is received in our office by midnight on Friday of any given week, we will release your funds to the bank the following Wednesday. Most participants see the funds in their account by Thursday, but it may take until Friday, depending on how quickly your bank processes the payment. For semi-monthly check reimbursement, the rules that govern reimbursement are in by the 5 th, out on the 15 th and in by the 20 th, out on the 30 th. For monthly direct deposit, the rule that governs reimbursement is in by the 5 th, out on the Wednesday prior to the 15 th.