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FAQ | Dependent Care
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Forms | Participants
Forms | Administrators

What You Need to Know

Filing a Flexible Spending Account (FSA) Request for Reimbursement

In order to process your reimbursement requests as quickly as possible, please remember these guidelines for submitting claims:

  • Complete a Request for Reimbursement Form and attach the proper documentation for the claim. This form is available from your Human Resource office, at our website (www.flexadministrators.com), or by phone at 1.800.968.3539 or 616.456.7908.
  • You may submit your Request for Reimbursement Form by mail, or by email.
  • Please make sure you submit the proper documentation with the claim. Proper documentation includes:

Explanation of Benefits (EOB)

from your insurance company. If you have medical, dental, or vision insurance and you are submitting a claim for payment in excess of your normal copay, please submit the EOB from your insurance company. The EOB will show us the total cost covered by insurance, and the remaining balance you were responsible for.

Itemized Receipt from the Provider of Service

including the provider’s name and address, date of service, patient’s name, description of services provided, and the amount of the charge. For vision claims we require the itemized receipt to show a breakdown of the individual services/items (exam, lenses, frames, etc.) and verification that the glasses have prescription lenses. Warranty charges are not eligible for reimbursement. If insurance has paid or is expected to pay any portion of the expense, the cost covered by insurance and the remaining patient balance must be listed. We cannot reimburse until we know what insurance has or is expected to pay.

Cash register receipts for over-the-counter and prescription expenses.

For over-the-counter and prescription expenses, cash register receipts will be accepted. Please make sure the name of the provider, date of service, description of expense and cost are visible on the receipt. You may also submit the prescription tab/sticker which shows the name of the patient, date the prescription was filled, name of medication, and the cost of the prescription instead of the cash register receipt.

For Orthodontia:

All first-time orthodontia requests must include the Truth in Lending statement or treatment contract from the orthodontist showing the provider of service, patient name, total cost of service, cost covered by insurance, down payment (if applicable), length of treatment, monthly payments amount, and beginning date and ending date of monthly payments.

Please note: We can only reimburse based on the payment plan specified in this contract. Also, in order to receive reimbursement, you must also submit a request for reimbursement on a monthly basis showing that the monthly payment was made.

LUMP SUM PAYMENT: If you pay for the entire orthodontic treatment up front, we will reimburse on a prorated basis if treatment goes into another plan year. You must still submit the Truth in Lending Statement and documentation showing that the treatment has been paid for in full. For example: Your plan year starts on January 1, 2008, your child has braces put on in March of 2008, and treatment is expected to last for 18 months. The total cost for the treatment is $3,000.00 which you pay for in full in March of 2008. We will take the $3,000.00 and divide it by the 18 months of treatment for a monthly fee of $166.67. Since you will have 10 months of treatment in the 2008 plan year, we can reimburse $1,666.70 in March of 2008. In order to receive the remaining balance of $1,333.30, you must participate in the plan the following year and request the additional reimbursement in January of 2009. We will keep your documentation on file and you will only need to submit a Request for Reimbursement Form. For adult orthodontia: A letter of medical necessity is needed stating why the orthodontic treatment is necessary. Any adult orthodontia for cosmetic purposes is not eligible for reimbursement.

A RECEIPT SHOWING A BALANCE DUE OR PAYMENT MADE ON ACCOUNT IS NOT CONSIDERED PROPER DOCUMENTATION.

Please keep in mind that we do not need to see when the payment was made, we need to see when the service was performed and when the expense was actually incurred.

For Office Visit Co-Pays:

Please see the Itemized Receipt from the Provider of Service paragraph above. However, if your doctor’s office does not provide you with a receipt that shows the description of expense, but it does show the provider name, patient name, date of service, co-pay amount, and description of service as co-pay, that will be sufficient documentation.


Please keep in mind that one of the most common reasons for a claim to be denied or delayed is because the Request for Reimbursement Form is not completed in full. Please make sure you fully complete the form and sign and date it at the bottom.

If you have any questions regarding
your documentation please contact us.
1.800.968.3539 or 616.456.7908


Required Documentation

For Dependent Care Expense Reimbursement

The dependent care spending account allows you to contribute a maximum of $5,000.00 pre-tax for one or more qualifying dependents. If you do not participate in the dependent care flexible spending account, the maximum benefit available through the tax credit when you file your taxes is $3,000.00 for one qualifying dependent and $6,000.00 for two or more qualifying dependents. If you have two or more qualifying dependents you are allowed to use the maximum $5,000.00 through a dependent care spending account, and then see if you also qualify for a maximum of $1,000.00 of the tax credit when you file your taxes (the difference between the $6,000.00 tax credit and the $5,000.00 dependent care account).

In order to process your reimbursement requests as quickly as possible, please remember these general guidelines for submitting claims:

  • Complete a Request for Reimbursement Form and attach the proper documentation for the claim. This form is available from your Human Resource office, at our website (www.flexadministrators.com), or by phone at 1.800.968.3539 or 616.456.7908.
  • Please make sure you submit the proper documentation with the claim. Proper documentation includes:
    • Submit an itemized receipt from the day care provider. The receipt must reference the from/through date of service and be signed by the provider (or on the provider’s letterhead).
    • You can prepare your own receipts, and leave the dates and amounts blank for your day care provider to complete. (The receipts don’t have to be formal – see sample below.

REMINDERS:

  1. The plan reimburses based on the dates of service. A check will not be issued until the last date of service has passed.
  2. The dependent care account can only reimburse with funds deposited into the account. If there are no funds available when you submit a claim, we will enter it into our system. As soon as additional funds are deposited, a check will be issued.

MAKING THE MOST OF YOUR SAVINGS:

To find out how to make the best use of your dependent care benefit, please see the examples below. These show that the best choice is affected by your income level and the number of dependents you have in day care. These examples are based on a married couple filing jointly with two or more children in day care, and are accurate at the time of printing.

* Tax credit percentages decrease as Adjusted Gross Income increases.
** $5,000 is the maximum contribution to a dependent care spending account.
*** State tax rates vary from state to state.
Note: Federal tax rates are based on Adjusted Gross Income.

To determine the best choice for you, please use these calculators.

If you have any questions regarding your documentation,
or determining the difference between
the tax credit and dependent care spending account,
please contact us at
1.800.968.3539 or 616.456.7908