How to Submit a Claim for Reimbursement
From your Health Savings Account
We offer four easy ways for you to access your Health Savings Account (HSA) funds. For fastest results, we encourage you to use your health care payment card (if applicable), the ConnectYourCare mobile app or submit your claim online. If you would like to submit your claim manually, please use the attached form.
Healthcare payment card
1. If your account included a payment card, you can use it to pay directly for services at eligible healthcare locations such as doctor’s offices, hospitals and pharmacies.
2. Always save your receipts; the IRS may require them at tax time.
ConnectYourCare mobile app submission
1. Download the ConnectYourCare mobile app to your Android, iOS or Windows device.
2. First time users create a username/password.
3. Click “Add new claim” from the main screen. Enter the requested information about your claim and continue through the screens to confirm and submit the claim.
4. You can take a picture of your receipts and upload them with your claim.
Online claim submission
1. Log in to your Premera online account at mysbuxben.com (or on premera.com/starbucks) and click on “Reimbursement Accounts” under Manage Health Coverage from the top navigation bar.
2. Select “Payments & Reimbursements” and follow the instructions to create a new claim. Each Claim Submission Form has a unique bar code and should only be used to submit documentation for that claim number.
3. If required, print the Claim Submission Form and fax it, along with the required itemized receipts or other documentation, to 866-741-0386.
Paper claim submission
1. If you didn’t use your payment card and are unable to access the ConnectYourCare mobile app or the Internet, complete the HSA Withdrawal Form, below.
2. Fax it to 866-741-0386.
3. If you choose to mail your claim form instead of faxing, the address is:
Claims Department
P.O. Box 622318
Orlando, FL 32862-2318
Health Savings Account (HSA) Manual Claim Form
Use this form to submit your claims for reimbursement of eligible expenses paid out of pocket that have not already been submitted.
· Do not use this form if expenses were already paid with your healthcare payment card.
· Do not use this form if you already submitted this claim via the ConnectYourCare mobile app or online.
· Complete all entries on this submission form. Please print or type.
· Sign and date this form.
· Fax or mail it to the claims department. (See submission instructions below.)
Personal InformationName of Employer
Starbucks
Employee Name (last name, first name)
/ Social Security Number
Claim Details
Date of Service / Patient’s Name / Relationship to Employee / Name of Provider /
Description of Service
/ Amount RequestedTotal / $
Authorization and Certification
Read carefully: This claim will not be processed without your signature.
I certify that I am the proper party to receive payments from this account and that all information provided by me is true and accurate. I further certify that no tax advice has been given to me by Premera Blue Cross or the HSA trustee and that all decisions regarding this withdrawal are my own. I expressly assume responsibility for any adverse consequences which may arise from this HSA withdrawal and agree that Premera Blue Cross and/ or the HSA trustee shall not be held responsible.
I understand that distributions made for purposes other than for qualified medical expenses are generally included in my gross income and, unless I have attained age 65 or am disabled, are subject to an additional 10% excise tax.
X
Signature Date
Submission Instructions
For fastest results, fax to: 866-741-0386 / Or mail to: Claims Department
P.O. Box 622318
Orlando, FL 32862-2318
For reimbursement account inquiries or for questions about your health plan, call
Premera Partner Services at 877-728-9020.
An Independent Licensee of the Blue Cross Blue Shield Association
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