A Flexible Spending Account (FSA) is funded by pre-tax contributions, therefore the IRS requires participants to comply with guidelines for reimbursement eligibility.

To substantiate a claim, please submit an itemized statement, itemized receipt or Explanation of Benefits (EOB) with the following:

• Date of service
• Description of services
• Amount billed for services
• Actual amount paid by insurance provider (if charges are submitted)
• Provider
• Patient’s name

“Previous Patient Balance”, “Balance Forward”, and “POA” (Paid On Account) amounts, or credit card receipts only, will not be eligible for reimbursement without an itemized statement or EOB to determine reimbursement eligibility and medical necessity of the services provided.