HomeMy WebLinkAboutFlex health care reimbursementti ThrivePass
Health Care Claim Form
VISIT APP.THRIVEPASS.COM TO FILE CLAIMS ELECTRONICALLY
•Enter your username and password
•Click on the "Pre-Tax" tile from your home page
•Click "File a Claim" from the "Manage Account" section
•Follow the instructions and enter claim information
•Upload your supporting documentation -see back of form for documentation requirements
•You can also sign up for E-mail/ Text Notifications & Direct Deposit
TRY OUR MOBILE APP AND FILE CLAIMS FROM THE PALM OF YOUR HAND
•Download the app called "ThrivePass Pre-Tax Accounts" from the Google Play Store or iOS app-store
•Set up your password, and away you go
•Upload your documentation, complete a few fields, and click "submit" -it's as easy as that!
PLEASE PRINT
Name ________________ _ SSN or Emp ID _*_*_*_-_*_* ____ _,/'-------
Address ________________ _ Daytime Phone# _____________ _
Employer Name _____________ _ D Please check box for change of address. Please also notify your Human Resources Department of the change
Instructions •Form must be fully completed, including signature and date -incomplete forms may delay processing•Enter one expense per patient per line -use multiple claim forms if necessary•Attach supporting documentation -see back of form for documentation requirements•Documentation will not be returned -please keep copies of your submissions
Date care was Amount of your Brief description of expense provided or item responsibility (e.g. Medical, Dental, Rx, Vision) was purchased after insurance
Person who received the
service or for whom the
item was purchased
I request payment from my Health Care account for the above expenses. To the best of my knowledge, these expenses are
eligible under the plan (see reverse side) and they are for myself or for an eligible dependent. I further certify that these expenses
have not been reimbursed under my major medical plan or any other health plan, such as an individual policy or my spouse's or
dependent's health plan, and that I will not seek reimbursement under any such plan. I understand that any expense for which
I am reimbursed may not be used to claim any federal income tax deduction or credit. I authorize ThrivePass to contact my
providers if my claim documentation is incomplete.
SIGNATURE
(required) -------------------DATE
ThrivePass, P.O. Box 220, Minneapolis, MN 55440-0220
Customer Service: 866-855-2844
Claims Fax: 888-265-5413
app.thrivepass.com
Health Care Expenses
IN GENERAL: -Eligible expenses are amounts paid for the diagnosis, care, mitigation, treatment or prevention of disease, or for the
purpose of affecting any structure or function of the body. Transportation expenses primarily for and essential to
medical care may be eligible. Expenditures that are merely beneficial to one's general health are not eligible.-Expenses incurred by you, your spouse or your eligible dependents that are not reimbursable from another source
(i.e. insurance} may be eligible for reimbursement. Expenses are not eligible for domestic partners or other
individuals who do not qualify as eligible dependents under your plan (see your SPD for more information}.-Expenses must be incurred during the period of coverage for which you made your election (including grace period},
and while you are an active participant in the plan (i.e. after your effective date and prior to your termination date).-Expenses are incurred on the date services are provided-not when the service or item is billed or paid for.-Any balance in your account after the claim submission cut-off date for a plan year will be forfeited.-Eligible expenses covered by medical/dental plans should be submitted to insurance first. Once insurance has paid,
you may request reimbursement of deductibles, co-payments, and co-insurances through your FSA.-Eligible expenses NOT covered by medical/dental plans may be submitted directly by completing the claim form and
attaching an itemized statement from your provider.
SPECIAL NOTICE REGARDING OVER-THE-COUNTER ITEMS.
Over-the-counter medications (unless excluded under your employer's plan} are eligible for reimbursement
Other non-medicinal OTC items (e.g. bandages, blood pressure monitors, contact lens solutions} are eligible in
"reasonable" quantities
Remember that adequate documentation is required. Cash register receipts are OK, but they MUST contain the date,
dollar amount and specific name of the item in order to be considered for reimbursement. No miscellaneous (i.e.,
"pharmacy," "Target, SO-count"} receipts will be accepted -even if accompanied by a box-top or label.
Note that by signing the front of this form, you are certifying that the OTC items have been purchased to treat a
presently existing or imminently probable medical condition and that they are not toiletries/cosmetics or items for
general health.
EXAMPLES OF INELIGIBLE EXPENSES:
Cosmetic procedures or related services / items (dental bleaching, electrolysis, propecia, etc.}
Weight loss prescriptions and programs (unless used to treat a diagnosed condition and the documentation includes
a letter of medical necessity from your physician}
Also:
Vision warranties -Marriage counseling -Prenatal/birthing classes
Sonicare toothbrush/spin brushes -Vitamins or nutritional supplements
DOCUMENTATION:
An Explanation of Benefits from your insurance company is the best type of documentation because it includes the necessary
information: date of service, description of service, patient name, amount charged, insurance payment, and we are able to tell
what portion of the cost is your responsibility.
If you are unable to submit the EOB, submit an itemized statement from the provider, which includes the following:
Date of service Description of service
Patient name Amount of expense; indication that payment is for a co-pay
Provider name Insurance payment, if applicable
Please note -Examples of unacceptable documentation are as follows:
Canceled check Balance forward or balance due statement
Credit card receipt or statement Payment on account receipt
Cash register receipt (except for OTC items ... the receipt must show actual name or RX number. 'Target 200 Count" is
not a specific enough description)
ThrivePass, P.O. Box 220, Minneapolis, MN 55440-0220
Customer Service: 866-855-2844
Claims Fax: 888-265-5413
app.thrivepass.com