benefitadminsolutions/anthem Login : Request for Reimbursement Health Flexible Spending Account

Submit an electronic claim through your online account at benefitadminsolutions.com/anthem. Check one of the boxes in the Supporting Documentation section.

Complete Claim Information in its entirety. Please ensure your supporting documentation clearly indicates the requested amount.

If you are enrolled in a traditional PPO medical insurance plan, you may also choose to enroll in an optional Flexible Spending Reimbursement Account for Healthcare expenses or Dependent Care expenses

Request for Reimbursement Health Flexible Spending Account

1. Complete all details on the next page. Or if you prefer, submit an electronic claim through your online account at benefitadminsolutions.com/anthem.

2. Check one of the boxes in the Supporting Documentation section.

3. Organize your documentation in the same order listed on the form.

• Please do not use a highlighter. If necessary, circle an expense on your itemized receipt.

• Use a paperclip if needed, but do not staple documents.

• If receipts are small, attach them to a standard size sheet of paper.

4. Sign and date the form.

5. Submit the signed form and copies of supporting documentation. Keep original documents and receipts for your records.

Online: benefitadminsolutions.com/anthem

Fax: 866-538-6972

Mail: Anthem Blue Cross and Blue Shield (Anthem) Claims
P.O. Box 650808
Dallas, TX 75265-0808

Also Read : Ochsner Health System: Sign On

Acceptable Supporting Documentation

• For office visits — Your health plan’s Explanation of Benefits (EOB) statement or an itemized receipt or bill from the provider that includes the patient’s name, a description of the service, the original date of service*, and your portion of the charge

• For prescription drugs — A pharmacy statement or receipt from your pharmacy including the patient’s name, the Rx number, the name of the drug, the date the prescription was filled, and the amount

• For over-the-counter medicines — A written or electronic OTC prescription along with an itemized cash register receipt that includes the merchant name, name of the OTC medicine or drug, purchase date, and amount, OR a printed pharmacy statement or receipt from a pharmacy that includes the patient’s name, the Rx number, the date the prescription was filled, and the amount.

• For over-the-counter health care-related products — An itemized cash register receipt with the merchant name, name of the item/product, date, and amount.

Please Note: Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

Medical expenses which have been reimbursed under this plan are not deductible for income tax purposes.

What expenses are covered under a health FSA?

Only “eligible expenses” can be reimbursed under the FSA. These expenses are defined by IRS rules and your employer’s plan. You can learn about your plan by reading the Summary Plan Description (SPD). Eligible health FSA expenses are those that you pay for out of your pocket when you, your spouse, or eligible dependents get medical care. The IRS says that this includes “items and services that are meant to diagnose, cure, mitigate, treat, or prevent illness or disease”. Transportation for medical care is also included.