Fillable Printable Health Care Reimbursement Account Request
Fillable Printable Health Care Reimbursement Account Request
Health Care Reimbursement Account Request
AD1113 08-11
ORIGINAL SUBMISSION
RESUBMISSION
Health Care Reimbursement
Account Request
A. INSTRUCTIONS
Complete sections B, C, and D
If expense is covered by insurance, submit to appropriate carrier
Attach explanation of benefits (EOB) from the insurance carrier or co-pay receipts
Itemized bills should include the following:
1) Provider name and address 2) Patient name 3) Itemized charges 4) Date of service 5) Type of service
Cancelled checks, non-itemized receipts and balance due bills are NOT ACCEPTABLE proof of expenses
If you have questions, please call: 800-826-9781, or contact us online at www.umr.com
Mail completed form along with appropriate documentation to: UMR
Attention: Flexible Spending Department
PO Box 8022, Wausau, WI 54402-8022
You can also fax claims toll-free to: 877-390-4782 or email them to umr-[email protected]om
B. EMPLOYEE INFORMATION
EMPLOYEE MEMBER IDENTIFICATION NUMBER
EMPLOYER
PLAN YEAR EXPENSE SUBMITTED FOR
(YYYY)
PHONE E-MAIL ADDRESS
EMPLOYEE LAST NAME EMPLOYEE FIRST NAME
ADDRESS
CITY STATE ZIP CODE
C. HEALTH CARE EXPENSES
DATE(S) OF
SERVICE FROM
MM/DD/YY
DATE(S) OF
SERVICE TO
MM/DD/YY
PROVIDER (I.E. DOCTOR
NAME/PHARMACY NAME
TYPE OF SERVICE (I.E., CO-
PAYMENT, OTC SUPPLIES, RX,
VISION, ORTHODONTIA, DENTAL
AMOUNT
REQUESTED
$
$
$
$
$
TOTAL REIMBURSEMENT REQUEST: $
If any of the amounts requested are to be used to offset an overpayment or substantiate a card transaction
please check here. (Please note: even if not checked claims will be used to offset any improper/unsubstantiated
card transactions before any reimbursement can be made)
D. CERTIFICATION
I certify that the expenses for which I am requesting reimbursement meet all of the following conditions listed below:
They were incurred for services or supplies by me or my eligible dependents under the plan.
They were for services or supplies furnished on or after the effective date of my IRS employee spending account.
I have not been reimbursed for these expenses in any other way.
I understand that reimbursement of these expenses should be requested and made only after I have collected all benefit payments available from all plans
under which my eligible dependents and I are covered. I further certify that I have not deducted or will not deduct on my individual income tax return any
of the expenses reimbursed through my health care spending account. I understand that reimbursement will be made in accordance with the provisions of
the plan. I accept responsibility for the proper treatment of benefits paid under this plan with respect to eligibility, income tax reporting, and liability.
EMPLOYEE SIGNATURE (REQUIRED) DATE
AD1113 08-11
Reimbursement Instructions – Please Review
Eligible Services and Documentation Requirements:
The expense must be a health-related expense incurred by you or one of your tax dependents. This means amounts paid for the
diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure of the body. Expenses must be
medically indicated and not for cosmetic purposes or general good health. A listing of eligible and ineligible expenses can be found online
at www.umr.com. Please note that effective 1/1/11 over- the- counter (OTC) items, such as drugs and medications will require a
prescription. Please refer to your Plan Document to verify OTC items are eligible.
Supporting Documentation
must accompany this request form. Please adhere to the following DOs and DO NOTs:
DO DO NOT
Send an itemized bill showing the dates of service, type of service,
provider name, patient’s name and amount of service
Send a copy of an explanation of benefits (EOB) from any
insurance plan under which the expense is covered. When
applicable your insurance claim must be finalized prior to
submitting for flex reimbursement.
Complete the total requested amount
Send the documentation on white paper. Carbon copies and
colored paper are not legible when scanned.
Tape small receipts to a standard 8.5” x 11” sheet of blank paper.
Ensure print is legible.
Include itemized receipts/documentation with the form.
Make a copy of the form and documentation for your personal
records.
Do not submit cancelled checks or credit card receipts alone.
These are not adequate documentation without supporting
itemization.
Do not submit balance forward statements.
Do not submit bank statements
Do not highlight names, prices or dates on receipts. They are not
legible when scanned.
Do not submit handwritten receipts for prescriptions or over-the-
counter items.
Do not submit pre-treatment estimates or estimated insurance
statements.
Do not submit date expense was paid, except for orthodontia
payments.
Actual Dates of Service
must be indicated on the claim form. The IRS allows reimbursement for services when the care is provided,
which may not be the actual date that the patient pays or is formally billed for the charges.
EOB E-mail Notification
allows you to receive an e-mail notifying you once your claim has been processed and an EOB is available to
view online. Signing up is easy and convenient at www.umr.com.
Web Claim Submission
allows you to submit your claim online at www.umr.com. Please print the cover sheet and fax it along with
your documentation to 866-881-1200.
Fax Verification
is available by calling 800-826-9781 and following the appropriate prompts. The Interactive Voice Response (IVR)
system can verify faxes received within the last 30 days.
Letter of Medical Necessity (LOMN)
is additional documentation needed when an item normally not considered eligible is needed to
treat a specific medical condition. This letter would need to be completed by your provider stating which service or item is needed and for
what type of condition. Generally LOMNs are needed for the following types of expenses. A LOMN is required annually.
Vitamins or supplements
Health club memberships
Massage therapy
Weight loss programs, including some food items
If you are not sure if a service or item will be covered, please contact UMR customer service.
Limitations on Reimbursement of Over-the-Counter Supplies (Stockpiling)
will be followed. You will only be reimbursed for a
reasonable quantity of an eligible over-the-counter medical care expense as determined by the plan administrator under the Plan (i.e., 10
boxes of band aids in one month would not be reasonable). Please refer to your Plan Document to verify OTC items are eligible.
Payments
are issued once the total reimbursement amount reaches your plan’s check minimum. Please contact UMR customer service
to verify this amount.
Automatic Reimbursement
may be a feature your employer has chosen. This feature allows any patient liability amounts to be
automatically reimbursed from your flexible spending account once your UMR medical, dental, and/or pharmacy claims are processed. If
you have a non-UMR provider for these services, automatic reimbursement may still be available. Please contact UMR customer service
to verify if this feature is allowed and if you are eligible to participate.
PLEASE NOTE:
If you have automatic reimbursement for any of the benefits listed above, please do not submit a
manual claim.
Health Savings Account (HSA) Owners Only:
I understand that (1) I may not submit any expenses that would apply toward the
deductible on my high-deductible health plan (HDHP) and (2) that I will be limited to reimbursement for dental and vision expenses only
through my flexible spending account (FSA).
