Documentation for Health Care and Dependent Care Flexible Spending Account Claim Submission

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

 

Health Care Flexible Spending Account

Health Care 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 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.  The Explanation of Benefits from the insurance plan will be required for processing.

Co-pay, Coinsurance, Deductible, any expense that includes insurance processing, or any expense covered by insurance (medical, dental, vision, including eye exams)

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

Prescription Medication

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

Orthodontia Expenses

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, orthodontia services span multiple plan years. The payment must be made during the applicable plan year in which the FSA is designated for. If there is coverage under any dental plan, payment from the Health Care FSA 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 claim using date of payment as 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 patient, name of provider, amount paid, date of payment, and description of services received
  • Subsequent submissions - submit claim using date of payment as date of service and include the following document:
    • Paid receipt showing: name of patient, name of provider, 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.

  • First submission - submit claim using date of payment as 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 a date of service from the same month of payment
    • Paid receipt showing: name of patient, name of provider, amount paid, date of payment, and description of services received
  • Subsequent submissions - submit claim using date of payment as date of service and include both of the following documents:
    • ​​​​​​​Explanation of Benefits showing a date of service from the same month of payment -or- copy of the check/payment mailed to you from the insurance company
    • Paid receipt showing: name of patient, name of provider, amount paid, date of payment, and description of services received

​​​​​​​Note: If your insurance plan pays more than expected after you have received reimbursement through your Health Care FSA, you are responsible for paying the "covered" portions back to your FSA. 

Over-the-Counter (OTC) medications

  • Valid prescription from medical provider listing first and last name of patient, date prescription was written, name of drug prescribed, the dosage prescribed, number of refills, and the provider’s information including name, address, and license number
  • Receipt clearly showing the item purchased

OTC items (Medical Supplies, First Aid Supplies, contact solution, etc.)

  • 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

Massage Therapy (for treatment of a medical condition)

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

Service not covered by insurance (e.g. acupuncture, contact lens fitting, LASIK, etc.)

  • Itemized statement from the provider with a clear description of service provided, name of patient, date of service, amount paid for service, and name of the provider
  • 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”

Expenses requiring a Letter of Medical Necessity

  • Letter of Medical Necessity completed by medical professional including specific medical diagnosis and specific recommendation PDF iconLetter of Medical Necessity
  • 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

 

Dependent Care Flexible Spending Account

Dependent Care 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

Receipts from the provider must include:

  • 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