Healthcare Expenses:

  • Complete a Flexible Spending Account (FSA) Reimbursement Claim Form.
  • If the eligible expenses can be reimbursed through a healthcare plan, you must submit the expenses to that plan first.  You will receive an Explanation of Benefits (EOB) statement, which explains the benefits paid and/or denied by your healthcare plan.  Attach the EOB to the Flexible Spending Account (FSA) Reimbursement Claim Form.
  • If the eligible expenses are not reimbursable by any other source, you must provide an itemized receipt, which contains all of the following information:
  • Service provider name/address
  • Date of service (date expense was incurred, not paid)
  • Itemized description of expense
  • Amount of expense

 

Dependent Care Expenses:

 

  • Complete a Flexible Spending Account (FSA) Reimbursement Claim Form.
  • Be sure to complete all information.
  • Be sure to get a signed receipt form from your dependent care provider and attach to your completed form.
  • Provider receipt should list all of the following information:
  • Name, address, tax ID number, or social security number of provider of service
  • Name of dependent
  • Service dates:  from _______ to _______ (day/month/year) - not date paid
  • Amount paid for corresponding service dates/dependent care expenses

 

Paper claims may be submitted in one of the following ways:

Email claim forms and supporting documentation to:  flexbenefits@healthsmart.com
Fax claim forms and supporting documentation to: 844-319-3669
Mail claim forms and supporting documentation to:  HealthSmart Benefit Solutions, PO Box 16647, Lubbock, TX  79490-6647