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Understanding the IAA FSA HRA Claim Form is essential for anyone utilizing Flexible Spending Accounts (FSA) or Health Reimbursement Accounts (HRA). This form serves as the key instrument for filing claims and seeking reimbursement for eligible medical expenses, and it demands careful completion to ensure a smooth process. Applicants are required to provide essential information, including their name, contact information, and the specific account type—either FSA or HRA. It's crucial to submit documentation that proves eligibility, as claims for expenses already covered by another insurance must be presented first to the primary provider before approaching IAA. The form also features sections for detailing multiple expenses, such as medical services and prescription costs, with a reminder that incomplete submissions will be returned. Furthermore, the claims must not include costs incurred for cosmetic purposes or general health items, adhering strictly to IRS guidelines. Along with the direct submission of the form, individuals should attach relevant proof of payment and service documentation to expedite claim processing. As you navigate this essential process, knowledge of the form's requirements and guidelines can lead to a more efficient claims experience.

Iaa Fsa Hra Claim Example

Contact Information & Claims Submission:

888-599-1515 ~ 856-470-1200

800-238-0876 (Fax)

[email protected]

IAA - PO Box 5082

Mt. Laurel, NJ 08054

 

 

 

 

www.iaatpa.com

 

 

FSA/HRA Claim Form

 

Please indicate the appropriate Account:

 

 

 

Flexible Spending Health Account (FSA)

Health Reimbursement Account (HRA)

 

 

 

 

 

 

 

NOTE:

Please remember claims reimbursed under the deductible must be presented to your primary

insurance carrier before you submit to IAA for reimbursement.

 

Employer Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

Social #

 

 

 

 

 

 

 

 

Address

 

 

 

Check box if this is a new address

 

 

 

 

 

 

City

 

 

 

State

Zip

 

 

 

 

 

 

Email

 

Phone

Check here if IAA Benefits Card USED

 

 

 

 

 

 

 

 

(IAA Benefits Card)

 

No prepayment of services should be submitted until the service has been provided. Expenses reimbursed (or reimbursable) by any medical, dental or vision insurance are not eligible. If you have questions regarding an eligible or ineligible expense, please feel free to contact us.

Please fill in all requested information and attach copies of receipts/statements of services you have received to this form. (Canceled checks, credit card receipts and proof of payment or notice of payment due will not be accepted.)

If this form is incomplete, it will be returned to you.

 

Expense # 1

Expense # 2

Expense # 3

Expense # 4

Date Medical Service or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item Actually Provided

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person

Name:

 

 

 

Name:

 

 

 

Name:

 

 

 

Name:

 

 

 

Self

 

 

Self

 

 

Self

 

 

Self

 

 

Receiving Medical Service

 

 

 

 

 

 

 

 

Spouse

 

 

Spouse

 

 

Spouse

 

 

Spouse

 

 

and His/Her Relationship

 

 

 

 

 

 

 

 

Dependent

 

 

Dependent

 

 

Dependent

 

 

Dependent

 

 

 

 

 

 

 

 

 

 

 

Type of Service Provided

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(glasses, contacts, scripts etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Participating

 

Yes

No

 

Yes

No

 

Yes

No

 

Yes

No

Provider*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Proof of Deductible/

 

Yes

No

 

Yes

No

 

Yes

No

 

Yes

No

Co-payment Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Deductible/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Co-payment Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reimbursement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*For HRA Plans, please select if the provider of service participates

 

 

 

 

 

 

 

 

 

 

 

 

with your health plan’s PPO/POS/HMO Network.

 

 

 

Total Reimbursement Requested

 

 

 

 

 

I authorize the above expenses to be reimbursed from my Health Spending Account. To the best of my knowledge, my statements on this Form are true and complete. I certify all of the following: Either I, my Spouse or my Dependent has received the services described above on the dates indicated, or the expenses qualify as valid Medical Care Expenses under Code Section 213(d), as further defined in the Plan document (the “Plan”). I certify that all drugs were obtained legally in the United States. These expenses have not previously been submitted for reimbursement under the Plan. They have not been reimbursed under this Plan or any other plan, and I will not seek reimbursement for them under the major medical plan or any other health plan. These expenses are for medical care excluding cosmetic purposes, are not incurred for general health purposes, and do not constitute toiletries. I understand that the expenses reimbursed may not be used to claim any federal income tax deduction or credit. I also understand that I may be asked to provide further details about some expenses (e.g. a statement from a medical practitioner that the expense is to treat a specific medical condition or a more detailed certification from me).

Employee Signature: ____________________________________________________

Date:

(Employee Signature must be provided in order to process this form)

 

1934 Olney Avenue * Suite 200 * Cherry Hill, NJ 08003

FSAclmfrm-Rev.03/2011

Contact Information & Claims Submission: 888-599-1515 ~ 856-470-1200 800-238-0876 (Fax) [email protected] IAA - PO Box 5082 Mt. Laurel, NJ 08054 www.iaatpa.com

FSA/HRA Claim Form Documentation

Medical Payments

All documentation should show date of service, procedure performed and should prove the claim was initially processed by your health care carrier. Acceptable documentation includes: a copy of the Explanation of Benefits (EOB) from your health care carrier and/or an itemized bill indicating services received for that person have been applied to the applicable deductible.

Dental and Vision

All documentation should show date of service, procedure performed or item(s) purchased and name of person receiving services/items.

The submission should include: copy of statement, itemized bill, or detailed receipt.

Prescription Drugs (Rx)

Provide a copy of the pharmacy receipt for the prescriptions(s). Usually, this is stapled to the bag containing your prescription(s). This will provide details, such as prescription name, price and fill date. In some Plans, the prescription benefits are subject to a calendar year deductible, before co-pays are applied. These should be submitted as well.

Over-the-Counter Purchases (OTC)

All documentation should include the itemized register receipt from the store of purchase. If your register receipt prints abbreviated product names, please provide unabbreviated product name to quicken processing time. All medication purchases incurred after 12/31/2010 must be accompanied by a doctor’s prescription.

This plan is governed by IRS guidelines. In order to satisfy IRS requirements documentation is needed to process your claim(s). When submitting for reimbursement, please complete and provide necessary documentation. This will quicken the processing time of your claim(s). Please visit our website www.iaatpa.com for additional forms.

1934 Olney Avenue * Suite 200 * Cherry Hill, NJ 08003

FSAclmfrm-Rev.03/2011

File Breakdown

Fact Name Fact Description
Contact Information For any questions or claims submissions, you can reach IAA at 888-599-1515 or via email at [email protected]. Fax submissions are accepted at 800-238-0876.
Eligible Expenses Expenses submitted for reimbursement must be valid medical care costs under IRS Code Section 213(d). This does not include cosmetic procedures, general health expenses, or toiletries.
Required Documentation All claims must be accompanied by appropriate documentation, such as an Explanation of Benefits (EOB) or itemized bills, showing the date of service and procedure performed.
State Governing Laws The IAA FSA HRA Claim Form operates under IRS guidelines and specific state laws may apply. For New Jersey, references to New Jersey state statutes can be relevant in certain claims situations.

Guide to Using Iaa Fsa Hra Claim

Filling out the IAA FSA HRA Claim Form is a critical step toward obtaining reimbursement for eligible medical expenses. Proper completion of the form ensures that your claims are processed efficiently and accurately. Follow the steps carefully to submit your claim without delays.

  1. Obtain the IAA FSA HRA Claim Form. Ensure you have all necessary documents on hand before proceeding.
  2. Begin by selecting the appropriate account type—either the Flexible Spending Account (FSA) or the Health Reimbursement Account (HRA).
  3. Fill in your employer’s name, your last name, first name, and social security number accurately.
  4. Provide your address. If you’ve recently moved, check the box indicating that this is a new address.
  5. Enter your city, state, and zip code, as well as your email address and phone number.
  6. Indicate whether you used the IAA Benefits Card for any of the expenses.
  7. List your medical expenses. Include the date service was provided, the name of the person receiving the service, and their relationship to you (self, spouse, or dependent).
  8. Specify the type of service provided (e.g., glasses, contacts, etc.) and confirm the provider's participation status with your health insurance network.
  9. Attach proof of deductible or co-payment documentation for each expense listed.
  10. Clearly indicate the total amount you are requesting to be reimbursed for each expense.
  11. Sign and date the form to authorize reimbursement from your Health Spending Account.

After completing the form, ensure you attach copies of all required receipts and statements that demonstrate the services received. Avoid sending canceled checks or credit card receipts, as these will not be accepted. Submit your claim to IAA using the provided contact information, and keep a copy for your records. Timely submission helps avoid any unnecessary delays in processing your reimbursement.

Get Answers on Iaa Fsa Hra Claim

What is the IAA FSA HRA Claim Form used for?

The IAA FSA HRA Claim Form is used to request reimbursement for expenses submitted to a Flexible Spending Account (FSA) or Health Reimbursement Account (HRA). This form must detail eligible medical, dental, or vision services that have been paid out of pocket and are eligible for reimbursement under your health plan.

How do I submit the IAA FSA HRA Claim Form?

You can submit the completed form along with the required documentation to the address indicated on the form. Alternatively, you may fax it to 800-238-0876 or email it to [email protected]. Ensure that all receipts and supporting documents are attached to expedite the processing.

What documentation do I need to provide with the claim form?

The documentation required will depend on the type of service you are claiming:

  • Medical Services: A copy of the Explanation of Benefits (EOB) from your healthcare carrier or an itemized bill.
  • Dental and Vision Services: An itemized bill or detailed receipt indicating the services received.
  • Prescription Drugs: A pharmacy receipt showing the medication name, price, and fill date.
  • Over-the-Counter Purchases: An itemized store receipt. A doctor's prescription is also required for OTC medication purchases incurred after December 31, 2010.

What happens if my claim form is incomplete?

If the claim form is incomplete, it will be returned to you. To avoid this, make sure all sections of the form are filled out correctly, and all necessary documentation is attached. This includes copies of receipts and any other supporting evidence required.

What expenses are not eligible for reimbursement?

Expenses that are reimbursed by any medical, dental, or vision insurance are not eligible for reimbursement under the IAA FSA or HRA. Additionally, expenses for cosmetic procedures or general health purposes, as well as toiletries, do not qualify. Always review IRS guidelines for eligible medical expenses to ensure compliance.

Who can receive services under my claim?

Claims can be submitted for services received by you, your spouse, or dependents. Each person receiving the service must be listed on the form, along with their relationship to you. It is important that the expenses are for eligible medical care services as outlined in your health plan.

Is there a deadline for submitting claims?

Do I need to provide a signature, and why?

Yes, your signature is required on the claim form. By signing, you are certifying that the information provided is accurate, the services were received, and you will not seek reimbursement from any other health plans for the same expenses. Ensuring this form is signed is essential for processing your claim.

Can I check the status of my claim?

You can check the status of your claim by contacting customer service at 888-599-1515 or 856-470-1200. It is advisable to have your claim number handy when you call to ensure a smooth inquiry process.

Where can I find additional forms or information?

For more forms or detailed information regarding the claim process, visit the IAA website at www.iaatpa.com. The website provides a variety of resources to assist with claims and reimbursements.

Common mistakes

Completing the IAA FSA HRA Claim Form can be straightforward, but mistakes do occur with surprising frequency. One common error is failing to fill out all requested information. Incomplete forms are often returned, which delays reimbursement. Make sure to provide every piece of information requested to avoid this issue.

Another frequent mistake is not including proper documentation. It's essential that all claims come with correct receipts or statements clearly indicating the date of service, the procedure performed, and the total amount charged. Canceled checks and credit card receipts are not acceptable. Without this documentation, claims may be rejected.

Many individuals overlook the stipulation regarding the eligibility of expenses. Claims for expenses that have or could be reimbursed by other medical, dental, or vision insurance are not eligible. Always confirm that any expenses claimed have not been reimbursed elsewhere.

People often miss the necessity of submitting claims for services after they have been provided. The guidelines clearly state that no prepayment for services should be submitted unless the services have already occurred. Submitting claims for future services is a common oversight that can lead to rejection.

Additionally, some claimants forget to check whether the provider is a participant in their health plan’s network. This information is crucial, especially for HRA accounts. If a provider does not participate, the claim may not be covered, leading to unnecessary complications.

Choosing the wrong account type between Flexible Spending Account (FSA) and Health Reimbursement Account (HRA) can create issues. Ensure you indicate the correct account by checking the appropriate box on the form. Mistakes in this regard can slow the processing of claims.

Moreover, many forget to verify their personal and contact information before submitting the form. Errors in contact details can result in communication issues, potentially delaying reimbursement notifications. Always double-check this information for accuracy.

Some individuals aren't aware of the requirement for a signature. The employee signature is mandatory to process the claim. Without it, claims cannot proceed, and this simple oversight can lead to considerable delays.

Finally, overlooking the time frame for submitting claims can be detrimental. Submissions need to be timely to ensure reimbursement. Familiarizing yourself with the deadlines for submitting claims can help avoid unnecessary stress and errors.

Documents used along the form

When engaging with the IAA FSA HRA Claim Form, there are several additional forms and documents that claimants may need to submit to ensure a smooth reimbursement process. Each of these documents serves a specific purpose and provides necessary information to support the claim. Understanding the requirements and types of documents involved can significantly enhance the efficiency of submitting claims. Below is a list of these additional forms and documents.

  • Explanation of Benefits (EOB): This document is issued by your health insurance carrier and outlines the services provided, the amount billed, and how much your insurance covers. It is essential as it shows that a claim was processed by your healthcare provider.
  • Itemized Bills: An itemized bill reflects the specific services rendered, detailing each procedure, the costs associated with them, and who received the services. This is particularly necessary for verifying charges submitted in claims.
  • Prescription Receipts: For claims involving prescription drugs, a copy of the pharmacy receipt is required. This receipt will typically include the name of the medication, the date it was filled, and the amount charged.
  • Over-the-Counter Receipts: When claiming expenses for over-the-counter medications, you must provide an itemized store receipt. Since certain medications require a doctor’s prescription, it's crucial to accompany these receipts with that documentation if applicable.
  • Proof of Deductible Payments: If claiming for services that fall under deductible coverage, documentation proving that the deductible has been met must accompany the claim. This may include statements or letters from your insurance provider.
  • Detailed Medical Statements: Occasionally, further verification is needed for specific medical expenses. A letter or statement from a healthcare provider may be necessary to confirm the necessity of a treatment or service.
  • Claim Cover Sheet: Some organizations require a cover sheet outlining the details of the claim, including your personal information and a brief description of the expenses. This helps streamline the submission process.
  • Authorization Forms: If needed, forms that authorize the sharing of your health information may be required, particularly when third-party claims are involved. This ensures compliance with privacy regulations.

Each of these documents plays a critical role in the claims process for FSA and HRA reimbursements. By preparing these forms in advance, individuals can minimize delays and complications when submitting their claims. It is always advisable to consult specific guidelines provided by the administrator of your benefits plan to ensure that all necessary documentation is submitted correctly.

Similar forms

The IAA FSA HRA Claim Form has several counterparts that serve similar functions in managing healthcare expense reimbursement. Here’s a list of documents that share characteristics with the FSA HRA Claim Form:

  • Health Care FSA Claim Form: Like the IAA form, this document is used to claim reimbursements from a Flexible Spending Account for eligible medical expenses. It requires similar information about the patient and type of services received.
  • Dependent Care FSA Claim Form: This form also focuses on reimbursement but for expenses related to dependent care services. It includes similar information fields about services provided and costs incurred.
  • HRA Claim Form: Specifically tailored for Health Reimbursement Accounts, this form allows participants to submit claims for eligible medical expenses. It asks for detailed service information, just like the IAA claim form.
  • Flexible Spending Account Enrollment Form: While this document is primarily for enrollment, it often requires similar personal and employer information to establish eligibility for FSA claims.
  • Explanation of Benefits (EOB): The EOB details what services were covered by insurance and how much can be claimed. It is often used in conjunction with the claim form to ensure expenses are verified before submitting for reimbursement.
  • Prescription Claim Form: For medications, this form is submitted to claim reimbursements for prescription costs. It collects information specific to drug purchases, akin to what the IAA form does with general medical expenses.
  • Out-of-Pocket Medical Expense Reimbursement Form: This form allows individuals to claim back expenses not covered by their primary insurance. It requires similar supporting documentation and expense details to process claims efficiently.

Dos and Don'ts

Things You Should Do When Filling Out the IAA FSA HRA Claim Form:

  1. Fill in all requested information completely.
  2. Attach copies of receipts or detailed statements for services you received.
  3. Use the correct account type: Flexible Spending Account (FSA) or Health Reimbursement Account (HRA).
  4. Ensure that your employer's name is clearly mentioned.
  5. Sign and date the form to authorize reimbursement.

Things You Shouldn't Do When Filling Out the IAA FSA HRA Claim Form:

  1. Do not submit claims for services or expenses not covered by your medical, dental, or vision insurance.
  2. Avoid submitting canceled checks or credit card receipts; these will not be accepted.
  3. Do not submit prepayments for services before they have been provided.
  4. Refrain from submitting claims without proper documentation; incomplete forms will be returned.

Misconceptions

Misunderstanding the IAA FSA HRA Claim form can lead to unnecessary delays and frustrations. Here are nine common misconceptions to be aware of:

  • You can submit just any document for reimbursement. Many think that any receipt will suffice, but only specific documents are accepted. You must include itemized bills, Explanation of Benefits (EOB) statements, or pharmacy receipts.
  • Prepayment for services is allowed. Some individuals believe they can request reimbursement before receiving services. This is incorrect; services must be provided before submitting claims.
  • Your expenses don’t need to be processed by your primary insurance first. This is a critical misunderstanding. Claims that are eligible under your deductible must go through your primary insurance before reaching IAA for reimbursement.
  • Cosmetic procedures are reimbursable. Many believe that expenses for cosmetic purposes qualify for reimbursement. However, only expenses for medical care are eligible, excluding those for general health or toiletries.
  • Cash register receipts are enough for over-the-counter items. This is not true. If the register receipt features abbreviated product names, you must provide the full product names to avoid delays.
  • You don’t need to provide details about every expense. Some people think they can just submit receipts without any additional information. However, further details may be requested to clarify eligibility.
  • Claims can be submitted without filling out all required information. Incomplete forms will be returned, so ensure all sections are filled out to prevent delays.
  • You can claim expenses for your pets. A surprising number of people believe they can request reimbursement for pet care expenses. Only expenses for medical care pertaining to human dependents qualify.
  • Reimbursed expenses can still be claimed on your tax returns. Expenses that are reimbursed through these plans cannot be deducted on your federal income tax returns. Understanding this can help you avoid double-dipping.

Getting familiar with these misconceptions is vital for a seamless claims process. Stay informed, and always double-check the requirements before submitting your forms!

Key takeaways

Filling out the IAA FSA HRA Claim Form properly is essential to ensure swift processing and reimbursement of your medical expenses. Here are five key takeaways to keep in mind:

  • Account Selection: When completing the form, ensure that you select the correct account type—Flexible Spending Account (FSA) or Health Reimbursement Account (HRA). This choice is crucial for proper processing.
  • Required Documentation: Attach clear copies of receipts or statements for the services received. Acceptable documentation includes itemized bills or Explanation of Benefits (EOB) from your health care provider.
  • Ineligible Expenses: Be aware that expenses reimbursed by other health insurance policies do not qualify. Claims that include cosmetic procedures or general health purposes are also ineligible.
  • Completeness Counts: Fill out the form completely; incomplete forms will be returned. Ensure that all necessary fields, such as your personal details and service information, are accurately filled.
  • Filing Timeliness: Submit claims only after the services have been provided. Advance payment for services is not allowable, and claims must first be processed by your primary insurance carrier if applicable.

Following these guidelines can help streamline the claims submission process and enhance the likelihood of receiving timely reimbursements.