How To File A Claim

Instructions on Filing for FSA Reimbursement

If you made a payment with your FSA Debit Card, click here to read the instructions on substantiating those purchases. For other transactions, there are three ways for Participants to file FSA Reimbursement claims: Online, by Fax, and by Mail.

File Your Claim Online

Register for a New Account

1. Make sure you have your Employer’s Employer ID and your Benefit Debit Card Number handy.
2. Click here to register a new user account.

Log In to Your Account

1. Click here to log in to your account.
2. If you’ve forgotten your username, click here to have your username re-sent to you.

Submit Your Claim

1. Select the Submit Claims option located under the Claims on the menu bar.
2. Complete the required fields.
3. Upload your documentation.
4. Check the statement verification box and click Submit.
5. You will have the option to add additional claims after submitting the initial claim.
6. You can check the status of your claim by going to the Claims Activity option under the Claims tab on the main menu. If the status is Pending, your claim is still being processed.

File Your Claim by Fax

1. Complete a Reimbursement Request Form. Download that form by clicking here.
2. Gather related documentation. This documentation must include the date(s) of service, the provider of services, what procedure(s) was done, and the amount you are being charged. Charge receipts, canceled checks, balance forwards, and paid on account receipts are not acceptable forms of documentation. Acceptable documentation includes:
   • Itemized Statements
   • Explanation of Benefits (EOB)
   • Pharmacy Printouts of Prescriptions for each amount claimed
3. Fax your completed Reimbursement Request Form and documentation to (844) 859-7308.

File Your Claim by Mail

1. Complete a Reimbursement Request Form. Download that form by clicking here.
2. Gather related documentation. This documentation must include the date(s) of service, the provider of services, what procedure(s) was done, and the amount you are being charged. Charge receipts, canceled checks, balance forwards, and paid on account receipts are not acceptable forms of documentation. Acceptable documentation includes:
   • Itemized Statements
   • Explanation of Benefits (EOB)
   • Pharmacy Printouts of Prescriptions for each amount claimed
3. Mail your completed Reimbursement Request Form and documentation to:
   Attn: GGA Claims
   P.O. Box 16509
   Jackson, MS 39236

Tips for Submitting Your Forms

Cafeteria Plan Reminders

We must have a Reimbursement Request Form with proper documentation in order to be in compliance with IRS regulations. Make sure you have signed, dated, and put your employer’s/company’s name in the appropriate place. State of Mississippi employees, please denote the agency. In signing the form, the participant is providing a written statement that the expenses have not been reimbursed or are not reimbursable under any other source.

Medical Care Reimbursement

• Expenses are treated as having been incurred when the participant is provided with the medical care that gives rise to medical expenses, not when the participant is formally billed or charged for, or pays for the medical care.
• Canceled checks, balance forwards, and paid-on-account receipts are not sufficient documentation relating to the nature of the expense (for what and whom it was incurred) rendered by an independent third-party provider. Similarly, charge card receipts do not generally include the required information.
• An Itemized Statement from the provider or an EOB (Explanation of Benefits) from an insurance carrier is sufficient documentation. An Itemized Statement should include the following:

1. Provider’s Name and Address
2. Patient’s Name
3. Dates of Service
4. Description of Services
5. Amount Charged

Dependent Care Reimbursement

• Dependent care must be necessary for a single parent or a married couple to work or to look for a job. It must also be for day care purposes only. Educational programs are not eligible; therefore, kindergarten is not an allowable expenditure. Remember, the child(ren) must be under the age of 13 years. Partial year qualifications do apply (i.e. if the child turns 13 on July 15, you can count dependent care expenses through July 14).
• Remember to attach Form 2441 to your Form 1040 when filing your taxes.
• Remember, the dependent care account is not a pre-funded account, so money must be in the account in order to reimburse the participant.

If you have any questions about submitting your FSA claims, call Glynn Griffing & Associates office at (601) 982-0331.