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Click ‘Get Form’ to open the fsafeds reimbursement form in the editor.
Begin by filling out all account holder information, including your last name, first name, and ID code (last four digits of your Social Security number).
In the 'Provider Name' section, enter the name of the healthcare provider who rendered services.
Fill in the 'Service Dates' for both start and end dates of the services received.
For each patient listed, provide their name, relationship to you (self, spouse, qualifying child, etc.), and type of service received.
Ensure that you include documentation requirements such as Explanation of Benefits (EOBs) or a letter of medical necessity where applicable.
Review all entries for accuracy before submitting your claim electronically through our platform or printing it for fax/mail submission.
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Please save your receipts and other supporting documentation related to your HC FSA expenses and claims. The IRS may request itemized receipts to verify the eligibility of your expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.
How to submit a FSAFEDS claim?
How do I submit a Federal Flexible Spending Account Program (FSAFEDS) online claim? You can submit your claim online by logging into My Account Summary at .FSAFEDS.com , clicking on My Claims, and selecting Online Claim Submission. You must upload an image of your supporting documentation in .
What documentation is needed for FSA reimbursement?
The service documentation will need to include: Provider Name Service Dates (not payment date) Patient Name Type of Service Out- of-Pocket Cost or Your provider may sign the form confirming the date of services, charges and other service or product information in lieu of providing separate documentation or
What is acceptable documentation for FSA reimbursement?
For office visits: Your health plans Explanation of Benefits (EOB) statement or an itemized receipt or bill from the provider that includes the patients name, a description of the service, the original date of service and your portion of the charge.
How do I reimburse FSA expenses?
With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasnt been covered by your plan. Then, youll get reimbursed for your costs.
Related Searches
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Remember, to be accepted for a claim, youll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).
Related links
Eligible Expenses for a Health Care Flexible Spending Account
This list describes expenses that are frequently submitted for reimbursement under Health Care Flexible Spending Accounts and are generally considered eligible.
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