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University Benefits Flexible Spending Accounts

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The following lists are common claims for both Health Care and Dependent Care and the standard documentation required for processing.

Health Care Flexible Spending Account

Claims should be submitted using the following information:

  • date of service, not the date of payment
  • name of the provider of service or vendor of purchase
  • name of the patient
  • amount paid for service (or the amount listed as patient responsibility on EOB)

NOTE: Medical expenses that can be reimbursed to you through any other source, such as group health insurance, are not reimbursable. Per IRS and Plan guidelines, any expense covered by an insurance plan must be processed through that insurance plan before consideration can be given for reimbursement from a Health Care Flexible Spending Account.  Our FSA team auditors will require the Explanation of Benefits from the insurance plan for processing.

Required Documentation

Required Documentation:

  • Explanation of Benefits (EOB) from the insurance company
  • Itemized statement for any expense listed on EOB but not covered by an insurance plan (visit service not covered by insurance section below)

Required Documentation:

  • Rx tag from the pharmacy showing the name of the patient, name of the drug, name of vendor/pharmacy, date of fill, cost of prescription/amount paid, and insurance plan (if applicable).

IRS regulations allow a Health Care FSA plan participant to be reimbursed for orthodontia expenses, up to the elected annual amount, as payment is made.

The date of payment is considered the date of service for orthodontia services only. Often, orthodontic services span multiple plan years. The plan participant must make the payment during the applicable plan year for which the FSA is designated. If there is coverage under any dental plan, the Health Care FSA payment will be reduced by the amount paid by insurance.

Documentation Requirements:

Delta Dental Providers: 
Participating providers will accept payment arrangements and file claims for you with Delta Dental of Iowa. Payment is made directly to these providers.

  • First submission - submit a claim using the date of payment as the date of service and include both of the following documents:
    • Treatment Contract (sometimes called your payment plan, financial agreement, or truth in lending statement)
    • Paid receipt showing: name of the patient, name of the provider, the amount paid, date of payment, and description of services received
  • Subsequent submissions - submit a claim using the date of payment as the date of service and include the following document:
    • Paid receipt showing: name of the patient, name of the provider, the amount paid, date of payment, and description of services received

Non-Delta Dental Providers: 
Non-participating providers do not have contracts with Delta Dental of Iowa. They do not agree to accept payment arrangements and are not responsible for filing claims for you. Non-participating providers may charge more for dental care than participating providers. Payment is made to you, and you are responsible for paying the provider.

  • The first submission - submit a claim using the date of payment as the date of service and include all of the following documents:
    • Treatment Contract (sometimes called your payment plan, financial agreement, or truth in lending statement)
    • Explanation of Benefits from insurance showing date of service from the same month of payment
    • Paid receipt showing: name of the patient, name of the provider, the amount paid, date of payment, and description of services received
  • Subsequent submissions - submit a claim using the date of payment as the date of service and include both of the following documents:
    • Explanation of Benefits showing date of service from the same month of payment -or- a copy of the check/payment mailed to you from the insurance company
    • Paid receipt showing: name of the patient, name of the provider, the amount paid, date of payment, and description of services received
Note: If your insurance plan pays more than expected after receiving reimbursement through your Health Care FSA, you are responsible for paying the "covered" portions back to your FSA. 

Required Documentation:

  • Receipt with a clear description of the item purchased, the amount paid for the item, the date of purchase, and the name of the vendor
  • NOTE – if the item is covered by insurance (e.g., wheelchairs, breast pumps, crutches, walkers, etc.), the EOB will be required for processing.

Required Documentation:

  • Receipt with a clear description of service provided, name of the patient, date of service, the amount paid for service, name, and license number of the massage therapist
  • Gratuity is not an eligible expense

Required Documentation:

  • Itemized statement from the provider with a clear description of service provided, name of the patient, date of service, the amount paid for service, and name of the provider
  • A signed statement indicating there is no insurance coverage for the service provided
  • For contact lens fittings at UIHC Ophthalmology Dept, the document is an “Itemized Receipt for Flex Spending.”

Documentation Required:

  • Letter of Medical Necessity completed by a medical professional including specific medical diagnosis and specific recommendation. You will find the Letter of Medical Necessity (LMN) form on our Benefits Resources page under the forms section >> Flexible Spending Accounts >> Health Care Spending Account.
  • Receipt with a clear description of the item purchased, the amount paid for the item, the date of purchase, and the name of the vendor

    Required Documentation:

    Consideration of reimbursement requires a valid Letter of Medical Necessity to be included with the claim or already on file with the Benefits Office.

    Reimbursement for gym memberships and/or exercise programs require a statement or invoice from the gym/facility displaying:

    • the participant's name
    • the name of the facility
    • a description of services provided for the charges
    • the amount of the charges
    • the date of payment

    If the changes are for a set period of time, our FSA team can process the claim after the time period. If the charges are for several sessions, the claim can be processed when all the sessions have been incurred.

    Dependent Care Flexible Spending Account

    Claims should be submitted using the following information:

    • dates of care, not the date of payment
    • name of the provider
    • name of the dependent(s)
    • amount paid for service for the specific dates of care

    Required Documentation

    Required specifics should be present on receipts for child care:

    • dates of care (not the date of payment)
    • name of the provider
    • Tax ID or SSN of the provider
    • total amount paid
    • indication the receipt is for childcare
    • indication of who paid for the services
    • signature of provider or receipt on company letterhead if a childcare center

    If your provider does not have a standard receipt with all of the above, you may use the Dependent Care Spending Account Receipt Template which can be found on our Benefit Resources page under the Forms section >> Flexible Spending Accounts >> Dependent Care Spending Account.