Fsafeds Claim Form PDF Details

Navigating the realm of healthcare expenses can often feel overwhelming, but the FSAFEDS Claim Form serves as a beacon for federal employees seeking reimbursement for out-of-pocket healthcare costs. Tailored exclusively for use with Health Care Flexible Spending Accounts (HCFSAs), this form facilitates reimbursement for a broad array of medical expenses, from the partially covered by FEHB or other health plans to those not covered at all. A visit to the FSAFEDS website unlocks a comprehensive list of eligible expenses, ensuring users can confidently identify what qualifies for reimbursement. The process is straightforward: complete the form with pertinent details, attach the required documentation such as the Explanation of Benefits (EOB) or itemized receipts, and submit all through fax or mail. It's imperative to meticulously follow the instructions to avoid delays or denials, including the use of capital letters for filling out the form and the restriction against stapling documents. For expenses that extend beyond the provided space, additional pages are available, underscoring the form's flexibility to accommodate a range of healthcare financial needs. Engaging with the FSAFEDS Claim Form is more than an administrative task; it's a step toward maximizing the value of HCFSAs, ensuring federal employees and their families can lessen the financial burden of healthcare expenses.

QuestionAnswer
Form NameFsafeds Claim Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesfsafeds health claim, fsafeds health care claim form, fsafeds health online, fsafeds claim form

Form Preview Example

HOW TO REQUEST REIMBURSEMENT FROM YOUR HEALTH CARE ACCOUNT

Use this form to request reimbursement for your health care expenses only. To view a detailed list of eligible medical expenses, visit

FSAFEDS Eligible Expenses Juke Box at www.FSAFEDS.com. Remember, you should first submit health care expenses under your FEHB or other health care plan you may have before you request reimbursement from your Health Care Flexible Spending Account.

Use this form only to request reimbursement for:

฀฀Allowableexpensescovered,butnotfullyreimbursed,byanybeneャtplans.฀฀Attachcopyoftheplan'sExplanationofBeneャtsStatement(EOB)

oritemizedreceiptfromyourprovider.

฀฀Allowableexpensesnotcoveredbyanybeneャtplans.Attachbillsorreceiptswhichindicatethenameandaddressoftheprovideroftheproductorservice and description of the product or service provided.

Step 1: Fill out the form

Please type or print in capital letters, with your letters centered in the boxes provided and fill in all ovals as shown:

 

YESNO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Section 1: Complete all areas of “Employee Information.” You may use your User ID instead of your SSN in part 1 of the claim form. You will receive an email confirming receipt of your claim.

For Sections 2 & 5: Fill in your expense – you can use one line to show a total of multiple expenses within the same Coverage Code. However, the expenses will be processed separately, and will be reflected as separate amounts on your account.

฀฀Completeallsectionsoftheform.Signanddatethebottomoftheform.

฀฀Pleaseusepageforadditionalexpensesifyouexceedthenumberoflinesprovidedonpage2.

Step 2: Attach supporting documentation. Please refer to the Clean Claim Quick Reference Guide for details.

In addition to completing the form, you must submit the documentation described under EITHER A OR B below:

A. Explanation of Benefits Form (EOB): This is the form you typically receive each time you or a health care provider submit medical, dental or vision claims for payment to your health, dental or vision care plan. The EOB will show the amount of expenses paid by the plan and the amount you must pay. For expenses

thatarepartiallycoveredbyyour,oryourdependent's,oryourthroughage26adultchild'smedical,dentalor vision plan(s), you must attach the EOB.

B. All Other Expenses:฀฀Forexpensesnotcoveredatallbyyour,oryourdependent's,oryourthroughage26adult child’s medical, dental or vision plan(s), or when you do not receive an EOB, your claim must include acceptable evidence of your expenses. A cancelled check is not considered acceptable evidence. Acceptable evidence includes receipts which contain the following information:

฀฀Typeofserviceorproductprovided

฀฀Dateexpensewasincurred

฀฀Personororganizationprovidingtheserviceandproduct

฀฀Amountofexpense

OTC Medicine/Drugs. Please refer to the OTC Medicines Quick Reference Guide for details. – You must submit copies of the prescription, label of the box/container, as well as your receipt.

OTC Non-Medicine/Drugs – If your receipt does not clearly show the name of the product, you must submit copies of the label from the box/container.

Step 3: Read the Certification and then sign and date the form where indicated

Step 4: Submit your form

•฀฀By฀Fax:Faxtheformandsupportingdocumentationto1-866-643-2245(toll-free).฀฀IfyouaresendingfromoutsidetheUnitedStates,pleasefaxto1-502-267-2233.

•฀฀By฀Mail: Place the form and the supporting documentation into an envelope, apply the correct postage,

andmailtoFSAFEDSProgram,POBox36880,Louisville,฀K40233.

฀฀Keepcopyofyourcompletedformandreceiptsforyourrecords.

PleaserememberthatFSAFEDShasminimumreimbursementthresholdof฀$25.00.Ifyourclaimdoesnottotal฀$25.00,itwillbeprocessedandyouwillreceivereimbursementstatement,butyourpaymentwillbependeduntilyousubmitanotherclaimandreachthe฀$25.00aggregateamount,oruntiltheendofthe

quarter, whichever comes first.

COVERAGECODES฀–฀YoumustincludecodeinSectionsandoftheform.

Medical codes

Dental code

102฀=฀over-the-counternon-drugs/medicines

฀฀฀฀฀202฀=฀฀generaldental(e.g.,cleanings,x-rays,

103฀=฀prescriptionsorprescriptionco-pays

crowns,implants,denturesoruse102or

104฀=฀generalmedical(e.g.,co-pays,deductibles)

117forover-the-counteritems)

203฀=฀orthodontia

117฀=฀over-the-counterdrugs/medicines

 

 

(prescription required)

Vision code

120฀=฀mileage

฀฀฀฀฀303฀=฀฀฀generalvision(e.g.,exams,glasses,contact

Other code

lensesoruse102or117forover-the-counter

items)

฀฀฀฀฀999฀=฀other

 

Type of Supporting Documentation:

Itemizedreceiptfromyourmedical,dental

or vision provider or pharmacy

ExplanationofBeneャts(EOB)fromyour฀฀฀฀฀฀฀฀฀฀

insurance company or health care provider ฀฀Prescriptionwrittenbyyourhealthcare

provider which must include:

-The date

-The name of the patient for whom the OTC item is prescribed

-The name of the OTC item (if you purchase a generic item, you must provide documentation that supports that it is the therapeutic equivalent to the prescribed drug)

-The dosage requirement (the potency of the item purchased must match the prescribed amount)

-The number of refills (unless it is a one-time purchase)

-The provider’s address and license number

Helpful Hints:

Add together similar expenses from the same Coverage Code and place that total on one

line (e.g., several over-the-counter items – Code102,multipleprescriptioncopays฀– Code103,etc.).FSAFEDSwillprocessthem

separately and they will be reflected as separate amounts on your account.

Provide the span of dates of service

(e.g.01/01/0806/30/08)

Enter the total amount on one line

Be sure to include legible receipts for each expense included in the overall total

BesuretouseyourFSAFEDSUserID ウBesureyoursignatureislegible

BesurecopiesofOTClabels,ifrequired,are

clear enough to fax

TheTotalRequestedboxwillautomatically

calculate the sum of expenses you list on page 2,orpagesand3.

Please Do NOT :

Emailyourclaimform ウUseredink

Usephotocopyofthisform

Usehighlighteronyourreceiptsorany

part of the form

Stapleyourcopiedreceiptstotheform ウWriteoutsidetheboxesprovided

Faxthesameformmorethanonce

Mailthesameformthatyouhavefaxed

Includethisinstructionsheetwithyourfax

Please DO:

Circle applicable items on your receipts (just don’t use a highlighter)

Useasmanysheetsforadditionalexpensesas

you need

Usecode฀999฀foranyeligibleitemthatisn'tcovered by one of the other Coverage Codes

Questions? Need a list of eligible expenses? Go to www.FSAFEDS.com or contact an FSAFEDS Benefits Counselor at 1-877-FSAFEDS.

Page 1 - HEALTH CARE CLAIM FORM

 

 

 

MAIL: FSAFEDS Program

 

 

 

 

HEALTH CARE CLAIM FORM

 

 

 

 

 

 

 

 

 

 

PO Box 36880

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UseonlyCAPITALLETTERS

 

 

 

 

 

 

 

 

 

 

Louisville, KY 40233

 

 

 

 

WKBVDY

 

 

 

 

 

 

FAXTO:฀฀1-866-643-2245฀฀TOLL-FREEor1-502-267-2233

 

 

 

PHONE: 1-877-FSAFEDS

 

 

 

 

 

 

 

For additional expenses, please use next page.

 

 

 

 

 

(1-877-372-3337)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TTY:1-800-952-0450

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 1: EMPLOYEE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEEUSERID(NODASHES)

 

 

 

 

 

PROGRAMNAME

 

INTERNALUSEONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FSAFEDS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEELASTNAME

EMPLOYEEFIRSTNAME

 

EMPLOYEEEMAIL

 

DAYTIMEPHONE(AREACODEFIRST,NODASHES)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2: YOUR HEALTH CARE EXPENSES

EXPENSE 1

DATES OF SERVICE

AMOUNTREQUESTED(DOLLARS . CENTS)

 

 

 

 

FROM฀฀(MMDDYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVERAGE CODE (SEE PAGE 1)

TO฀฀(MMDDYY)

FAMILYMEMBER'SNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

YESNO

EXPENSE 2

DATES OF SERVICE

AMOUNTREQUESTED(DOLLARS . CENTS)

 

 

 

 

FROM฀฀(MMDDYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVERAGE CODE (SEE PAGE 1)

TO฀฀(MMDDYY)

FAMILYMEMBER'SNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

YESNO

TOTAL REQUESTED (SUM OF EXPENSES FROM ALL PAGES SUBMITTED)

SECTION 3: CERTIFICATION Please read carefully before signing.

$

.

 

 

 

 

 

 

 

 

I affirm that:

฀฀฀I HAVENOTALREADYBEENPAIDFORTHESEEXPENSESFROMMYFSAANDHAVENOTREQUESTEDand WILLNOTRECEIVEREIMBURSEMENTFOR

THESEEXPENSESFROMANYOTHERPLANINCLUDINGFEDVIP(Federal Employees Dental and Vision Insurance Program) and FEHB (Federal Employees Health Benefits Program); AND

฀฀฀I havesubmittedtheaboveinformationingoodfaithanditiscorrecttothebestofmyknowledge.฀฀

I understand that:

฀฀Reimbursementisnotguaranteethatthispaymentistax-free.

฀฀Theservice(s)forwhichamrequestingreimbursementmustbeincurredduringmyperiodofcoverage,whichbeginsthenextJanuaryifenrolledduringtheOpenSeason,orthedayaftermyenrollmentisacceptedbyFSAFEDS,whicheverislater,andendsnolaterthanMarch15ofthefollowingyear,unlessmycoverageendssoonerduetoQualifyingLifeEvent.฀฀

฀฀฀I haveuntilApril30followingtheendoftheBeneャtPeriodorendofFederalServicetosubmitmyclaimforreimbursementofeligibleexpenses

incurred during my period of coverage. If I do not submit claims for reimbursement by that date, I will forfeit any funds remaining in my account(s) in accordance with IRS rules.

฀฀฀I cannotusehealthcareexpensesreimbursedthroughmygeneralpurposeHCFSAorLEXHCFSAasdeductiononmypersonalincometaxreturn. ウTheexpensesforwhichamrequestingreimbursementareformyself,myspouse,mydependentoradultchildthroughage26.

฀฀I authorizereleaseofpaymentthroughmyFlexibleSpendingAccount.฀฀authorizeFSAFEDS,oritsrepresentatives,toobtainnecessaryinformationfromallphysicians,hospitals,medicalserviceproviders,pharmacists,employers,andallotheragenciesororganizations(includingotherinsurers)toconsider

the claim for reimbursement under my Flexible Spending Account.

Employee Signature*

 

Date (MMDDYY)

 

*Your signature and date are required in order to process your claim for reimbursement.

USEANORIGINALFORM(NOTPHOTOCOPY)

Page 2 - HEALTH CARE CLAIM FORM

WKBVDY

COVERAGE CODE (SEE PAGE 1)
EXPENSE 4
COVERAGE CODE (SEE PAGE 1)
EXPENSE 5
COVERAGE CODE (SEE PAGE 1)
EXPENSE 6
COVERAGE CODE (SEE PAGE 1)
EXPENSE 7
COVERAGE CODE (SEE PAGE 1)
SECTION 4: EMPLOYEE INFORMATION (ABBREVIATED)
EMPLOYEEUSERID(NODASHES)
EMPLOYEELASTNAME
SECTION 5: YOUR ADDITIONAL HEALTH CARE EXPENSES
EXPENSE 3DATES OF SERVICE FROM฀฀(MMDDYY)

USE THIS PAGE FOR ADDITIONAL HEALTH CARE EXPENSES.

HKLUMD

EMPLOYEEFIRSTNAME

AMOUNTREQUESTED(DOLLARS . CENTS)

$

 

 

 

 

.

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

 

 

 

 

TO (MMDDYY)

 

 

 

 

 

FAMILYMEMBER'SNAME

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF SERVICE

AMOUNTREQUESTED(DOLLARS . CENTS)

FROM฀฀(MMDDYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO (MMDDYY)

FAMILYMEMBER'SNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

YESNO

DATES OF SERVICE

AMOUNTREQUESTED(DOLLARS . CENTS)

FROM(MMDDYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO (MMDDYY)

FAMILYMEMBER'SNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

YESNO

DATES OF SERVICE

AMOUNTREQUESTED(DOLLARS . CENTS)

FROM฀฀(MMDDYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO (MMDDYY)

FAMILYMEMBER'SNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

YESNO

DATES OF SERVICE

AMOUNTREQUESTED(DOLLARS . CENTS)

FROM฀฀(MMDDYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO (MMDDYY)

FAMILYMEMBER'SNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

DOCUMENTATIONATTACHED?

YESNO

USEANORIGINALFORM(NOTPHOTOCOPY)

Page 3 - HEALTH CARE CLAIM FORM

HKLUMD

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How you can fill in care claim stage 1

2. Soon after the previous part is filled out, go on to enter the suitable information in these: Usecodeforanyeligibleitemthatisnt, Questions Need a list of eligible, and Page HEALTH CARE CLAIM FORM.

Page   HEALTH CARE CLAIM FORM, Questions Need a list of eligible, and Usecodeforanyeligibleitemthatisnt of care claim

3. The following segment should be fairly straightforward, FSAFEDS, SECTION YOUR HEALTH CARE EXPENSES, EXPENSE, DATES OF SERVICE FROM MMDDYY, COVERAGE CODE, SEE PAGE, EXPENSE, DATES OF SERVICE FROM MMDDYY, SUPPORTING, YES, and SUPPORTING - all of these form fields must be filled out here.

DATES OF SERVICE FROM MMDDYY, SEE PAGE, and FSAFEDS inside care claim

4. Your next section requires your details in the following places: COVERAGE CODE, SEE PAGE, YES, SECTION CERTIFICATION Please read, TOTAL REQUESTED SUM OF EXPENSES, and I affirm that I. Make sure that you give all of the needed details to move onward.

Filling in part 4 in care claim

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Employee Signature Your signature, Page   HEALTH CARE CLAIM FORM, and I affirm that  I in care claim

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