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 user name, click here to have your user name re-sent to you.

Submit Your Claim

  1.  Select Submit Claims option on left side of the page.
  2.  Click Add New button. Through the process, you will have the option to submit the claim online or print a form to fax with documentation.
  3. Fill in required claim information. Make sure to select appropriate Service Category Code.
  4. Click Browse to locate file to upload, then click OK or just click OK to create a claim form to fax with documentation.
    Note: Dependent Care is listed in Service Category Codes.
  5. To add additional claims, click Add New.
  6. When finished adding claims, check the Certification box and Submit.
  7. If you uploaded documentation, you are finished.
  8. To print claim form to fax, click View Receipt Transmittal Form and fax with your EOB (Explanation of Benefits), pharmacy receipts, or itemized bill.
  9. If Glynn Griffing & Associates has an email address on file, you will receive an email confirmation of the online claim submission.
  10. You can check the status in Claims Pending. If the status indicates Pending, then we are still processing your claim. If your claim is no longer there, it has been processed and the details can be seen in the Transaction History section.

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, cancelled 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, cancelled 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.

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