New Employee Guide PC Health FSA Claim Form 2025

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Health Care FSA and Limited Expense Health Care FSA You must have a receipt or an explanation of benefits from your insurance carrier for each health care claim you submit against your account.
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 .
Youll have to typically submit a reimbursement claims form with: your personal details, product/service details(provider information) amount owed. date of service provided.
You can only get reimbursed for claims incurred during the previous FSA plan year. The run-out period is usually 90 days after the plan year ends. For example: If your FSA plan year ended on December 31, 2024, the run-out period ends on March 31, 2025.
We can provide an itemized receipt that you can submit to your FSA administrator for reimbursement. On the form you submit for reimbursement from your FSA, youll need to include personal details and information about the product or service you receive, any amounts owed and the date of the service provided.
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Complete FSA claim form and include: Payment coupon for monthly appointment; or, Itemized statement and payment receipt if claiming one upfront payment (if allowed under your plan). Hint: Some employer plans have specific payment requirements.
FSA Health Care Claim Forms are available online at .myuhc.com or via the Intranet at . Complete the claim form, then mail or fax to UHC with your itemized bill(s) or Explanation of Benefits (EOBs) for reimbursement.

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