Fill - Free fillable HR Flexible Spending2014 (Valencia College) PDF form

2012

VALENCIA COLLEGE FLEXIBLE BENEFITS

Flexible Spending Account Reimbursement Claim Form

Please read the attached instructions carefully. Incomplete claim forms or claim forms missing required documentation will

not be processed. Claims received after the Payroll deadline will be processed on the following paycheck.

EMPLOYEE/DEPENDENT HEALTH CARE EXPENSES (List dates of service separately; attach additional sheet(s) as needed)

TYPE OF EXPENSE

SERVICE DATES

From To

NAME OF

PATIENT\RELATIONSHIP

PROVIDER OF

SERVICE

AMOUNT

REQUESTED

TOTAL HEALTH CARE AMOUNT REQUESTED:

DEPENDENT CARE EXPENSES (not for dependent medical expenses)

NAME OF DEPENDENT AND

RELATIONSHIP

PERIOD OF

DEPENDENT CARE

PROVIDER

AMOUNT

REQUESTED

TOTAL DEPENDENT CARE AMOUNT REQUESTED:

I certify that I have actually incurred these expenses and I have not previously been reimbursed for them. I understand that

any amounts reimbursed cannot be claimed on my spouse's and/or my personal income tax for the purpose of income or tax

reduction. Where applicable, the above health care claims have been processed by any applicable coverage and the

documentation is attached. No other insurance has paid or is responsible for this/these claims. I further understand that any

amounts remaining at the end of the year that cannot be claimed will be forfeited.

DEPENDENT WITH NO INSURANCE ATTESTATION: Initial line and check the box only if applicable:

I certify that the patient/dependent, listed above, does not have any insurance coverage responsible for payment of

this claim; therefore, I have attached itemized medical receipts instead of Explanation of Benefits from an insurance

company.

Signature Date ________________________________

HUMAN RESOURCES USE ONLY

PAYROLL USE ONLY

Amt to reimb:

Date reimbursed:

Signature:

Date:

HR Form #36

Revised 01/12

Employee Name:

VID:

Mail Code:

Campus Ext:

DEP:

MED:

(Initial)

Clear Form

2014

$ 0.00

HR Form #101

Revised 01/14

INSTRUCTIONS FOR COMPLETING

FLEXIBLE SPENDING ACCOUNT (FSA) REIMBURSEMENT CLAIM FORMS

What should be listed in the sections above?

List health care/medical items for you and your eligible dependents in the section labeled,

“EMPLOYEE/DEPENDENT HEALTH CARE EXPENSES.” Attach documentation. Mail the completed

claim for and documentation to Mailcode 3-33, Human Resources. Keep copies for your records.

Expenses you pay for care of a dependent(s) so that you can be gainfully employed should be listed under the

section labeled, “DEPENDENT CARE EXPENSES.” These expenses may include, but are not limited to, child

care or after-school care for children under age 13, summer day camp (no overnight camps), etc. Attach

documentation. Mail the completed claim form and documentation to Mailcode 3-33, Human Resources. Keep

copies for your records. (Advanced reimbursement of future or projected expenses is not permitted under

Dependent Care Flexible Spending Accounts. Expenses for care of your eligible dependent that are provided by

another eligible dependent (i.e., older sibling) cannot be claimed for reimbursement.)

What forms of documentation are ACCEPTABLE for reimbursement?

EMPLOYEE/DEPENDENT HEALTH CARE EXPENSES:

All health care documentation must contain the name of the patient, the date of service, type of service, the

place of purchase, and amount you owe to the provider. The best form of documentation is the insurance

company’s Explanation of Benefits (EOB) which clearly shows the amount that you are responsible to pay the

provider of the service. Most insurance companies have websites where you can log in and pull copies of these

EOBs.

Rx/pharmacy receipts must list the name of the patient, the date of service, the place of purchase, Rx number,

and amount paid. If you turn in claims at the end of the plan year, you can request a list of your medications for

the year from the pharmacy. As long as it contains the information noted above, it is acceptable documentation.

DEPENDENT CARE EXPENSES:

All dependent care documentation must show that the expense has been incurred and be in the form of an

itemized bill, receipt, or contract for the amount claimed and include the dependent’s name; the period during

which the services were rendered; the name, address, and taxpayer identification number (TIN) of the individual

or organization providing the services; and a description of the service provided.

What forms of documentation are UNACCEPTABLE for reimbursement?

Cash register receipts, credit/debit card receipts, and canceled checks are not permitted forms of documentation

for reimbursement under flexible spending accounts. Doctors/Dentists’ statements do not contain all of the

information required to substantiate a flexible spending account claim; therefore, they are not acceptable forms

of documentation.

How and when will reimbursement be made?

Once the completed Flexible Spending Account (FSA) Reimbursement Claim Form and acceptable

documentation has been received, it will be processed and the money included in your next available paycheck.

For a list of payroll deadlines, refer to the following link:

http://valenciacollege.edu/HR/Full-

TimeEmployees.cfm . Claims, with acceptable documentation, received after the payroll due date will be

processed on the next available pay cycle.

Page 2: FREQUENTLY ASKED QUESTIONS

“Why can’t I submit a receipt for what I paid and get reimbursed?”

The amount you paid to the provider, in some cases, may not accurately reflect the amount you actually owe the

provider based on the insurance company’s schedule of benefits. If the provider overcharged you, you will need

to go back to that provider with a copy of your EOB, which shows what you actually owe to the provider, and

request a refund. This overcharge cannot be reimbursed from your flexible spending account.

“What if it’s a non-covered service or the dependent doesn’t have insurance?”

Claims, for non-covered services or for dependents without health insurance, will be processed as long as a

fully-itemized receipt is submitted that contains the name of the patient, the date of service, type of service, the

place of purchase, and amount paid. For dependents without health insurance, the box above the signature line,

on the claim form, must be checked and initialed. Documentation (e.g., EOB showing non-covered service,

exclusions page from Summary of Benefits, etc.) that the service is non-covered is still required unless the

health care coverage is through the college and the non-covered service is clearly defined in the CIGNA

Summary of Benefits.

“What types of expenses can I submit for reimbursement?”

Many items that are not covered by health insurance are eligible for reimbursement. These may include, but are

not limited to, copays, coinsurance, deductibles, services for alternative medicine (e.g., acupuncture, massage

therapy, etc.) if substantiated by a physician, etc. Of course, the list is too numerous to include here; therefore,

you should contact Human Resources if you have any questions.

Rule of thumb: If the item(s) and/or service(s) are required/prescribed by a physician for the treatment of an

illness, disease, or to improve a deformity arising from or directly related to a congenital abnormality, a

personal injury resulting from accident or trauma, or a disfiguring disease and are eligible medical expenses

under Code Section 213, they are most likely eligible expenses for reimbursement through a flexible spending

account. Items that promote general health and well-being (e.g., vitamins, special food, etc.) are not eligible

expenses through a flexible spending account with or without a doctor’s prescription unless the doctor provides

documentation that the item is required to treat a specific illness or disease.

Premiums cannot be reimbursed through a flexible spending account. For example, if you pay premiums for a

dependent child to have an individual health insurance policy outside of the college, those premiums cannot be

claimed for reimbursement through a flexible spending account.

Effective January 1, 2011, over-the-counter expenses that remain eligible for reimbursement are items such as

band-aids, contact lens supplies and solutions, reading glasses, etc. Over-the-counter items have been

eliminated as a covered expense unless prescribed by a physician such as acid controllers, baby rash ointments,

laxatives, allergy & sinus, cold sore remedies, anti, diarrheal, etc.

“What’s the time frame for submitting claims?”

You can only submit claims for reimbursement for the dates of service in which you are employed. For newly-

hired employees, the date of service must be after the effective date of your coverage which is the first day of

the month following your date of hire. For terminating or retiring employees, including 4-month faculty off

contract for the summer, the dates of service must be prior to the effective date of the end of your coverage

which is the first day of the month following your date of termination, retirement, or that your contract ends.

For example, any dates of service prior to midnight of the 30

or 31

of the month in which your coverage ends

are eligible. You have 90 days following the effective date in which your coverage ends to submit your

claims for reimbursement. Employees continuously employed have until March 31 of the following year to

submit claims for the prior plan year; however, expenses must have been incurred in the prior plan year.

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