Fillable Printable Medical Care Reimbursement Request - Dartmouth College

Medical Care Reimbursement Request - Dartmouth College

Crosby Benefit Systems, Inc. – 866-918-9711 – Fax: 978-367-9626 - servicecenter@crosbybenefits.com

P.O. Box 25172, Lehigh Valley, PA 18002-5172 - www.crosbybenefits.com - version 0111

Flexible Benefits Plan

MEDICAL CARE Reimbursement Request

PLEASE PRINT CLEARLY CROSBY BENEFIT SYSTEMS, INC.

Employee

Information

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Employee Name _____________________________________________________________________

Last First MI

Employer ___________________________________________________________________________

SSN / Employee ID _____________________________

Home Address _______________________________________________________________________

Street City State Zip

Email Address _____________________________________

Home Phone (______)_____________________ Work Phone (______)_______________________

area code area code ext.

Expenses

Please list all out-of-pocket unreimbursed eligible medical expenses, as defined in the Summary Plan Description

(SPD), for which you are requesting reimbursement.

Description of Expense Date of Service Amount*

__________________________________________________ ______________ ____________

*Do not include amounts paid or eligible for payment under any other

health care plan or program, federal, state or governmental

program,

Workers’ Compensation, or any other policy of health

insurance.

TOTAL EXPENSES $____________

Include with this form all “Supporting Documentation” as defined in the Important Information

section on the reverse side of this form. Retain a copy for your records. Canceled checks are not

acceptable. Failing to submit Supporting Documentation will delay (or prevent) claims processing.

Employee

Certification

Please

SIGN

By submitting this form, I hereby certify the following:

 All expenses identified above are “Eligible Medical Expenses” as defined in the SPD (Note: You can find general information

regarding Eligible Medical Expenses in the Important Information section on the reverse side).

 All expenses were incurred by me (the employee), my legal spouse, or an eligible dependent as defined in the SPD (Note:

You can find general information regarding the definition of legal spouse and eligible dependents in the Important Information

section on the reverse side).

 I have not been reimbursed nor will I seek reimbursement of the expenses listed above from any other source (e.g. under a

spouse’s employer’s plan).

 I will not deduct the above listed expenses on my personal federal and/or state income tax return for any year. My employer

does not accept responsibility for direct payment to any individuals other than the employee.

I have read and understand both the information on the reverse side (or page 2) of this form and the fact that I can request a copy

of the SPD from the Employer if I do not currently have a copy.

Employee Signature _________________________________________ Date __________________

Please enter your SSN or Employee ID. Many employers use an

ID other than SSN with Crosby Benefit Systems. If you are unsure

which number to use, please contact us or your HR/Benefits

department. If you do not enter an SSN/Employee ID, Crosby will

attempt to identify you based on other information but this could

delay or prevent processing of your request.

Crosby Benefit Systems, Inc. – 866-918-9711 – Fax: 978-367-9626 - servicecenter@crosbybenefits.com

P.O. Box 25172, Lehigh Valley, PA 18002-5172 - www.crosbybenefits.com - version 0111

IMPORTANT INFORMATION

Please note: Nothing in this section is intended to supersede or replace the provisions of the Summary Plan Description (SPD). If there is a

conflict between this section of the Form and the SPD, the SPD controls.

Eligible Medical Expenses - In general, only expenses for “medical care” as defined in your SPD are eligible for reimbursement under the Medical

Care Reimbursement Account (as defined in Code Section 213(d) with notable exceptions). IRS Publication 502 (available at www.irs.gov)

summarizes medical expenses allowable as deductions for tax purposes. Publication 502 states as allowable some expenses which ARE NOT

reimbursable under a Medical Care Reimbursement Account (for example, insurance premiums). In all situations, only medical care expenses not

reimbursed from any other source are reimbursable.

Examples of eligible expenses include co-payments/deductibles, vision, hearing, dental, and most uncovered prescription drug expenses. Examples

of ineligible expenses include insurance premiums, vitamins/supplements for general good health, cosmetic procedures and products, and counseling

not related to a medical condition.

Please note: Effective January 1, 2011, over-the-counter medicines and drugs can be reimbursed only if prescribed by a physician. This

change does not apply to medical supplies such as insulin (even if purchased without a prescription), or other health care expenses such as

medical devices, eye glasses, contact lenses, bandages, co-pays and deductibles.

Legal Spouse and Eligible Dependents - Only eligible medical expenses incurred by you, your “legal spouse” or “eligible dependents” (as defined

in the SPD) are eligible for reimbursement. Generally, your legal spouse is your spouse as recognized by federal law. Your eligible dependents

include any individual who would qualify as an eligible dependent as defined in Code Section 105. Consult with a qualified tax or legal counsel to

determine if expenses incurred by individuals for whom you request a reimbursement qualify as your legal spouse or eligible dependents.

Supporting Documentation - For all expenses, attach bills or evidence of charges that clearly state all of the following:

1. Name of person receiving service (except for retail purchases)

2. Name of service provider

3. Nature of service or supplies (drug name if a prescription)

4. Amount of reimbursable expense under the plan

5. Date(s) of service

Medical and dental expenses covered partially by your health care plan(s) are generally allowable. Explanation of Benefits statements which contain

the above information may be submitted as supporting documentation. For over-the-counter products, provide a cash register receipt with product

information or include a copy of the box/bottle with cash register receipt. In many instances, you may be required to provide additional

substantiation as determined by the claims administrator. For example, a doctor’s note or physician’s prescription may be required for some expenses

to verify that the expense qualifies as medical care.

Medical Practitioner’s (Doctor’s) Notes - For some expenses, a medical practitioner note is required to verify that the expense qualifies as medical

care. To be allowable, a medical practitioner note may be written by a doctor of medicine, dentistry, podiatry or optometry; an authorized

chiropractor, an alternative healer; or other qualified medical practitioner. A medical practitioner note must contain all of the following items: 1.

date; 2. patient’s name; 3. medical practitioner’s name; 4. statement of medical necessity; 5. the prescribed treatment; and 6. the duration of treatment

required.

Cosmetic procedures (for example, teeth bleaching) and drugs (prescription and nonprescription) to be used for a cosmetic purpose are not

reimbursable. Under the plan, medical care “does not include cosmetic surgery or other similar procedures, unless the surgery or procedure is

necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or

trauma, or a disfiguring disease.” Expenses for transportation primarily for, and essential to, medical care are reimbursable. For such expenses,

information must be provided that states the nature of medical care (for example, “doctor’s appointment”) and the date service was provided.

Orthodontia expenses can be reimbursed in one full sum or in monthly installments. Proper documentation of procedure and payment plan must

accompany each claim form. For orthodontia expenses to be eligible, payment must have been made within the current plan year.

Submission of Reimbursement Requests – Fax (preferred), email or mail reimbursement requests. If your reimbursement request is denied, written

notification will be mailed to you or emailed if you have selected electronic communications delivery. You may resubmit expenses with proper

documentation, if applicable.

Please note - Service dates for reimbursable expenses must fall within the plan year (or during the grace period if adopted by the employer).

Expenses incurred before participation began or after participation has terminated will not be reimbursed. After enrollment, changes to a

reimbursement account may only occur when there has been a qualified change in status.

Reimbursement requests not submitted during the plan year must be submitted/received (pursuant to plan rules) and approved prior to the end of the

run out period. Contact your Human Resources Department or Crosby Benefit Systems for more information.