Fillable Claim Form Did you know you can submit (Boise State University)

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Claim Form Did you know you can submit (Boise State University)

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Claim Form
(Instructions on next page)
Employee Information
Last Name, First Name
SSN / Employee ID #
Home Address
(Street, City, State, Zip Code)
Please update my address on file
Phone Number
Employer Name
Email Address
Did you know you can submit paperless claims online or via the MyNavia mobile app?
Just take a picture and submit!
Day Care FSA Expenses
Service Date(s) Type of Service
Provider’s Name, Tax ID and/or
SSN
Services For Whom Age Net Cost
Total Reimbursement Request $ ____________________
Day Care Provider Certification: I certify that dependent care services were provided as indicated above.
Provider/Facility Name: ___________________________________________
Signer’s Name (Printed): __________________________________________
Provider’s Signature X____________________________________________________________
Date: ________________________________________________________________________
Health Care/Limited FSA/HRA Expenses
Type of Service
Provider’s Name
Services For Whom
Net Cost
Total Reimbursement Request $ ____________________
Signature
To the best of my knowledge my statements on this claim form are complete and true. I understand that I am solely responsible for the sufficiency,
accuracy, and veracity of claims and all information related to these claims submitted to my HRA, Health Care (“HCFSA”) or Day Care Flexible Spending
Arrangement (“DCFSA”), and that unless an expense for which payment or reimbursement is claimed is a proper expense under the HRA, HCFSA or DCFSA,
I may be liable for the payment of all related taxes including federal, state or city income tax on amounts paid from the HRA, HCFSA or DCFSA which relate
to such expense. I further understand that no day care tax credit is permitted for amounts for which reimbursement is made. I am claiming health care
reimbursement for eligible medical care expenses incurred by myself, spouse and/or dependents. Note: The IRS does not recognize Domestic Partners for
purposes of receiving tax-favored health benefits. For further information please contact your employer. I certify that these expenses have not been
reimbursed under this plan or by any other source and that they will not be reimbursed by any other source or insurance. By providing an email address, I
consent to receive all possible communications from Navia Benefit Solutions, agents, and subcontractors regarding the Plan via email. I may withdraw
consent at any time without charge by contacting Navia by phone, email, or mail. To update your email address contact Navia Benefit Solutions by phone,
email, or mail. You have the right to receive paper version of an electronic document free of charge. Software requirements will be provided with each
electronic document. I hereby authorize my HRA, HCFSA and/or DCFSA to be reduced by the amount(s) shown above.
Participant’s Signature X_______________________________________________________________________________
Date_______________________________________________
REV 2/2/2016
Claim Form Instructions
1. Complete employee information section. Be sure to write legibly to ensure proper processing.
2. Itemize your expenses in the table provided and attach copies of your documentation.
Documentation must clearly show the date of service, type of service, and final cost of service. Examples of acceptable
documentation include itemized bills/invoices, or the Explanation of Benefits (EOB) from your insurance carrier.
If your employer offers an HRA and you are enrolled in a plan that only offers reimbursement for deductible,
coinsurance, and/or copays an EOB is required for claim submission.
If the expense is a copay amount (multiple of $5 up to $500), a payment receipt is acceptable documentation.
Proof of payment is not required in order to reimburse medical/dental/vision services.
Prescriptions
Examples of acceptable documentation include the Rx label, payment receipt, or mail order statement showing the date
filled, Rx name or Rx #, and cost. You may also submit an itemized printout from your pharmacy.
OTC Medications & Drugs
Per IRS regulations, OTC medications and drugs with an active ingredient must be accompanied by a prescription in order to
be reimbursed from your FSA (ex. pain relievers, cold/allergy medication, ointments, Antacids). Once approved, prescriptions
will remain on file with Navia for future claim submissions. Prescriptions are valid for one year after the date written.
Alternative Treatments
Expenses that may be seen as merely beneficial to general health will require a Letter of Medical Necessity (LMN), showing
the treatment of a specified medical diagnosis. Examples include vitamins/supplements, herbs, weight loss programs,
cosmetic products and procedures. Please have your provider write a letter or complete our
Letter of Medical Necessity
template.
Dependent Care
Acceptable documentation includes an itemized bill/invoice, showing the date of service, type of service, and cost of service.
If the dependent is age 5 or older, the documentation must show the services are “for care,” and not educational in nature.
If you are unable to obtain sufficient documentation, you may have the provider sign the front of this claim form to validate
the services being claimed.
If you would like to automate your recurring day care expenses, you may do so by completing our Recurring Day care Claim
Form, logging onto our Participant Portal, and selecting the My Recurring Claims tool tile.
Please DO NOT submit the following types of documentation:
Statements showing estimated/pending insurance
Statements showing the claimed amount as a balance forward/previous balance
Statements showing the claimed amount as a prepayment for future services
Cancelled checks/copies of cashed checks
Personal bank statements
3. Be sure to sign the claim form and submit! Please fax, email or mail a signed claim form, but choose one method only.
General Claims Submittal:
Email: claims@naviabenefits.com
Fax: Local (425) 451-7002 or Toll-free (866) 535-9227
Mail: Navia Benefit Solutions
PO Box 53250 Bellevue, WA 98015
Phone: Local (425) 452-3500 or Toll-free (800) 669-3539
If your employer offers an HRA, Dental or Wellness plan, submit to:
Email: 105@naviabenefits.com
Fax: Local (425) 709-7125 or Toll-free (866) 831-6222
Mail: Navia Benefit Solutions
PO Box 53250 Bellevue, WA 98015
Phone: Local (425) 452-3421 or Toll-free (866) 897-1996
Claims status is available online. Please allow at least two (2) full business days for Navia to process your claim.
REV 2/2/2016
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Claim Form Did you know you can submit (Boise State University)

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Completed 17 August 2020

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