Fillable 125 Claim Form (College of Alameda)

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125 Claim Form (College of Alameda)

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©2016 Pension Dynamics Company LLC. All rights reserved.
FLEXIBLE BENEFIT CLAIMS
CONTACT INFORMATION
Benefits Department
Phone: (925) 956-0514
Fax: (844) 859-7309
Email: benefits@pensiondynamics.com
Address:
Customer Service
The best way to check your claim status is to log into your account online at
www.pensiondynamics.com. If you have not yet registered for an account, please contact
Pension Dynamics Company LLC. The website is available 24/7 and is a great resource
once you have registered.
Customer Service is available at (925) 956-0514 from 8 AM - 5 PM PST, Monday - Friday.
You can also email us at benefits@pensiondynamics.com. Please include your name and
your employer name on any correspondence sent to us but do not include confidential
information such as your Social Security Number.
2300 Contra Costa Blvd., Suite 400
Pleasant Hill, CA 94523
Website: www.pensiondynamics.com
Tips for Completing the Claim Form
• Fill out each section completely. Any incomplete forms will not be able to be processed.
• Type or write legibly.
• Don't forget to sign your form. The employee who is participating in the plan is required to sign the form, not your spouse or other dependent.
• Insurance Coverage: If insurance is paying ANY portion of the services that you are requesting reimbursement for, please check YES. If you do not
have insurance or if this item is not covered by your insurance, please check NO.
Things to Include with your Claim Form
• All Health Care substantiation must include:
Name of patient (you, your spouse or tax dependent) incurring the expense
The date services were provided or the date the item was purchased
Service Provider or Merchant Name
Description of Service/Purchase
Amount of Service/Purchase
•
An Explanation of Benefits (EOB) is recommended. If you have insurance coverage that is covering a portion of the services the EOB is sometimes
required.
• All Dependent Daycare substantiation must include the following:
Dates of Service (dates care provided, not when billed/paid for)
Description of Service
Dependent's Name
Care Provider’s Name
Provider’s Tax ID or SSN
Amount of Claim
If your provider does not give receipts Pension Dynamics can accept the provider's signature on the completed claim form as proof of your expense.
• Canceled checks, credit card receipts, and statements including "Previous Balance", "Balance Forward, or "Paid on Account" are NOT acceptable as
they do not contain all of the required information.
• Handwritten statements must be on provider’s letterhead or have a provider stamp containing their information.
Reminders for Submitting your Claim Form:
• Retain the original of all requests including the substantiation, sending us a copy of the documents only. Pension Dynamics is not responsible for
providing copies.
• Please allow 2 business days for your claim to be processed. Payments are not able to be issued until services have been incurred in full.
• If your claim is denied, you will receive a written statement telling you why the claim could not be processed. If we need further information the
denial letter will state what you can do in order to have your claim re-processed.
• Do NOT combine your claim with your co-workers' claims. It will cause a delay in processing and may not be processed at all.
• If possible, scan your Claim Form and all substantiation and email the documents to us at benefits@pensiondynamics.com. This is the preferred
method of claim submission as you will get a personal response back stating your claim was received.
• You may also Fax your Claim Form to (844) 859-7309
• If you mail your Claim Form please send only copies, not originals, to: Pension Dynamics Company LLC, Attn: Benefits Department,
2300 Contra Costa Blvd., Suite 400, Pleasant Hill, CA 94523-3987.
Important information before you begin
©2016 Pension Dynamics Company LLC. All rights reserved.
FLEXIBLE BENEFIT REIMBURSEMENT
FAILURE TO COMPLETE THIS FORM IN FULL MAY DELAY PAYMENT
Please consult your Employee Handbook or contact your Plan Service Provider to be sure your expense is eligible for reimbursement.
Company/Plan Name:
Name
SECTION 1. EMPLOYEE INFORMATION
Last Four Digits of SSN
Evening Phone NumberE-mail Address Daytime Phone Number
SECTION 2. HEALTH CARE CLAIMS (if you are enrolled in a Limited FSA, eligible expenses are limited to dental and vision care)
• Attach copy of Explanation of Benefits (EOBs) for deductible and coinsurance reimbursement requests.
• Attach itemized bills for expenses not covered by medical/dental/vision insurance. Itemized bills must include the date(s) of
service, patient's name, provider’s name, services provided, and amount of expense. Dual Purpose items must include
information proving medical need.
• Please contact Pension Dynamics for information on how to submit Orthodontia claims.
• Balance Forward Statements, Canceled Checks And Credit Card Receipts Are Not Acceptable.
Provider / Vendor Date(s) of Service
Name of dependent who
incurred the expense
Requested Amount
Total:
If you need additional space to list expenses, please use another form.
Insurance Coverage
Yes No
Paid for with
mySourceCard
™
SECTION 3. DEPENDENT DAYCARE CLAIMS
Requested AmountDate(s) of Service
Name of dependent who
incurred the expense
Provider / Vendor
Proof of expense must include dates of service, description of services, provider's name, amount of expense and provider's tax
identification number (T.I.N) or Social Security Number. If no receipt is available, complete the claim form and have your provider sign
where indicated. Handwritten receipts must include the provider's stamp or be on their custom letterhead.
Provider's SSN / TIN
Total:
Provider's Signature
I certify the above expenses qualify for reimbursement under the terms of the Flexible Benefit Plan. I specifically state that the expenses
listed have been incurred for the benefit of me and/or my eligible dependents. I have attached acceptable proof of expense to this form.
I certify that the above is correct and complete and that all out-of-pocket expenses reimbursed to me under this program will not be
deducted on my, or my spouse’s, personal tax return or be reimbursed to me or my dependents by any other means.
SECTION 4. EMPLOYEE AUTHORIZATION
Date
Employee Signature
Attach proof and submit via - Email: benefits@pensiondynamics.com or Fax: (844) 859-7309
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125 Claim Form (College of Alameda)

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Completed 25 July 2020

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