Submitting a Reimbursement Request is Simple!
Procedure:
- Visit our “Forms” section on our websites main menu (www.flexbene.com) to retrieve a Flexible Spending/Medical Reimbursement Voucher.
- Fill out Part I: Employee Information
- Fill out Part II, Part III, and/or Part IV – depending on which section you are requesting reimbursement for.
- Sign and Date the bottom of the Reimbursement Voucher
*If you are filling out an ONLINE Reimbursement Voucher, it is NOT necessary to submit a paper copy*
**KEEP YOUR ORIGINAL DOCUMENTATION FOR YOUR RECORDS AND SUBMIT A LEGIBLE COPY WITH YOUR CLAIM**
- Submit Necessary Documentation WITH your Reimbursement Voucher:
If You’re Covered By Insurance |
Submit your claim to the insurance carrier first and obtain an Explanation of Benefits (EOB)
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If You’re NOT Covered By Insurance |
Submit an itemized statement CLEARLY stating ALL of the following:
( You may request an itemized statement from your Health Care Provider) |
Dependent Day Care Expenses |
Include the following information:
(Be sure to have submitted your Dependent Care Registration Statement PRIOR to submitting for Dependent Care Expense Reimbursement) |
Prescriptions, Over the Counter Drugs, and Medicines |
Include the following: PRESCRIPTIONS:
**Note: A receipt without the prescription name is NOT eligible OVER-THE-COUNTER DRUGS/MEDICINE/MEDICAL ITEMS:
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Orthodontia |
Include the following:
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According to the IRS, the following are unacceptable documentation: - Cancelled Checks - Credit Card Receipts - Statements that say “balance forward”, “previous balance due” or “paid on account” - Statements for services not yet rendered - Pre-treatment estimates of services to be provided in the future - Statements that do not include the date of service - Statements that do not include description of service - Statements that do not include the providers name, patient’s name, and dollar amount owed. |
3. Reimbursement Vouchers and Necessary Documentation can be submitted by e-mail, fax, or mail.
- To submit by e-mail, send ALL documentation and Reimbursement Vouchers to info@flexbene.com
** You will receive an e-mail confirmation from a Customer Service Representative once your e-mail has been received and sent to our Claims Department. If you have not received an e-mail after 24 hours, your attachments may be too large and you will need to be resend in multiple e-mails.
- To submit by fax, send ALL documentation and Reimbursement Vouchers to 1-585-248-2488.
(Please do not mail your claim if you fax it)
- To submit by mail, send ALL documentation and Reimbursement Vouchers to:
M.A. Services
P.O. Box 587
Pittsford, NY 14534-0587
Please notify M.A. Services in writing if you have a change in address