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 by any insurance / Medical and dental expenses must be submitted to your medical or dental plan first. Health plan co-payments do not require an EOB, if you submit a receipt from your health care provider for the amount and indicate “co-payment” on the Claim Form. / An Explanation of Benefits (EOB) stating the name of the provider, the name of the patient, date/s of 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 covered by insurance / Acupuncture, Childbirth classes (for the mother only), Contact Lenses, Eyeglasses, LASIK, medical aids, medical information plans, Mental health services that are covered under your health plan, but you choose to pay out of pocket without submitting to your health care plan, certain infertility treatments * Please note this is not an exhaustive list of what may be reimbursable / A statement from the provider of the service clearly stating the provider’s name, address and phone number, the name of the patient, date/s of service, a description of the service performed, and the amount 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 (OTC) / Acne Treatment, Allergy Prevention and Treatment, Analgesics, Antipyretics, Antacids, Acid Reducers, Anti-arthritics, Anticandial (yeast), Antidiarrheal, Anti-fungal, Antihistamines, Anti-itch Lotions and creams, Asthma Medicines, Cold Sore/Fever Blister, Cold, Flu, Decongestant, Sinus, Contact Lens Supplies, Contraceptive/Family Planning supplies, Cough Suppressants, Dehydration, Denture Care, Diaper Rash, Ear Care, Eye Care, First Aid/Medical Supplies, Foot Care, Hand Sanitizers, Headache/pain relief, Hermorrhoidal Preparations, Home Diagnostic Tests or Kits, Lactose Intolerance Supplements, Medicated Lip Products, Migraine Relief, Motion Sickness, Nasal Strips and Topical Antibiotics, Sunscreen, Smoking Cessation, Wart removal, Lice Removal, Sleeping Aids, and Topical Steroids
*Please note that this list is not exhaustive of all eligible OTC items. / An itemized receipt indicating the name and address of the provider, the date of purchase, the name of the product, and the cost. If your receipt does not have all of this information you must submit a copy of the label with a dated receipt. If you are submitting a bill for an over the counter item that is potentially eligible (e.g. vitamins) you must submit a Letter of Medical Necessity (LMN) from your doctor.

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.