Flexible Spending Account Claims

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
• Amount paid
• Note: Balance due statements are NOT adequate to properly evaluate claims

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:

• HealthSmart Internet portal
• HealthSmart mobile app - click here to learn more about the mobile app
• 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