IMPORTANT INFORMATION REGARDING REIMBURSEMENTS
Eligible Health Care Services and Documentation Requirements:
The expense must be a health-related expense incurred by you or one of your tax dependents. This means amounts paid for the
diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure of the body. Expenses must
be medically indicated and not for cosmetic purposes or general good health. A listing of eligible and ineligible expenses can be found
online at www.umr.com
Supporting Documentation
must accompany this request form. Please adhere to the following DOs and DO NOTs:
DO DO NOT
Send an itemized bill showing the dates of service, type of
service, provider name, patient’s name and amount of service
Send a copy of an explanation of benefits (EOB) from any
insurance plan under which the expense is covered. When
applicable your insurance claim must be finalized prior to
submitting for flex reimbursement.
Complete the total requested amount
Send the documentation on white paper. Carbon copies and
colored paper are not legible when scanned.
Tape small receipts to a standard 8.5” x 11” sheet of blank
paper. Ensure print is legible.
Include itemized receipts/documentation with the form.
Make a copy of the form and documentation for your personal
records.
Include actual dates of service on the claim form. The IRS
allows reimbursement for services when the care is provided,
which may not be the actual date that the patient pays or is
formally billed for the charges.
Do not submit cancelled checks or credit card receipts alone.
These are not adequate documentation without supporting
itemization.
Do not submit balance forward statements.
Do not submit bank statements
Do not highlight names, prices or dates on receipts. They are
not legible when scanned.
Do not submit handwritten receipts for prescriptions or over-the-
counter items.
Do not submit pre-treatment estimates or estimated insurance
statements.
Do not submit date expense was paid, except for orthodontia
payments.
Eligible Dependent Care Services and Documentation Requirements:
The expense must be a dependent care-related expense incurred by you for one or more of your eligible dependents. This means
amounts paid for the care of your qualified dependent so you and your spouse can work or look for work. A listing of eligible and
ineligible expenses can be found online at www.umr.com
Supporting Documentation must accompany this request form. Please adhere to the following DOs and DO NOTs:
DO DO NOT
Submit services after they have been incurred.
Have the day care provider sign the front of the claim
form if the services have been incurred to eliminate the
need to send any other documentation.
Complete the total requested amount
Send the documentation on white paper. Carbon copies
and colored paper are not legible when scanned.
Tape small receipts to a standard 8.5” x 11” sheet of
blank paper. Ensure print is legible.
Make a copy of the form and documentation for your
personal records.
Do not submit balance forward statements.
Do not submit bank statements
Do not highlight names, prices or dates on receipts.
They are not legible when scanned.
EOB E-mail Notification allows you to receive an e-mail notifying you once your claim has been processed and an EOB is available
to view online. Signing up is easy and convenient at www.umr.com
.
Web Claim Submission allows you to submit your claim online at www.umr.com. Please print the cover sheet and fax it along with
your documentation to 866-881-1200.
Fax Verification
is available by calling 888-438-6105 and following the appropriate prompts. The Interactive Voice Response (IVR)
system can verify faxes received within the last 30 days.
Letter of Medical Necessity (LOMN)
is additional documentation needed when an item normally not considered eligible is needed
to treat a specific medical condition. This letter would need to be completed by your provider stating which service or item is needed
and for what type of condition. If you are not sure if a service or item will be covered, please contact UMR customer service.
Limitations on Reimbursement of Over-the-Counter Supplies (Stockpiling) will be followed. You will only be reimbursed
for a reasonable quantity of an eligible over-the-counter medical care expense as determined by the plan administrator under the Plan
(i.e., 10 boxes of band aids in one month would not be reasonable).
Payments are issued once the total reimbursement amount reaches your plan’s $10.00 check minimum.
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