Wisconsin Electrical

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	FSA Reimbursement Claim Form An error occurred. Your session may have expired. Please log in again. Flexible Benefit Reimbursement requests must be received by the Fund Office no later than one year (twelve months) following the date on which the expense was incurred. Request for reimbursement must total a minimum of $100, however, the Plan permits participants to submit one reimbursement request in December of each year for less than $100.00. Select the Explanation of Benefits (EOB) from your claim history that you wish to file for reimbursement. If there is a secondary insurance carrier on you, or any eligible dependent, you must submit (upload) that secondary insurance carrier’s EOB to show your final out of pocket balance for which you are filing for. If you are submitting reimbursement for prescription co-pays or a print-out from your Pharmacy, please make sure to sort and name your upload file to make sense for your flex records which will appear under your payment history (ie…Jane Doe – Walgreen Pharmacy Jan 1, 2020 thru June 30, 2020). A Doctor’s prescription must be submitted with any over the counter medicine, supplies, creams, vitamins etc. before any reimbursement can be made from your flex account. Any durable medical equipment rental or purchase (crutches, wheelchairs, walkers, etc…) OR charges that are NOT eligible under your Health and Welfare plan, will require an itemized bill from the Provider with proof of payment unless processed through the insurance which then generates an EOB under your claim history records. If submitting reimbursement for a spouse’s group health coverage premium, you must complete two (2) forms, 1) The Employer Verification Form for Health Insurance Premium Expenses (Employer to complete); and 2) Form for Employees Seeking Reimbursement of Health Insurance Premiums (Employee to complete) along with proof of payment. Find a claim Submit Without a Claim Number Current FSA Balance: Total Amount Claimed: Pending FSA Claims: If this Flex Reimbursement request is for more than the amount in my Flex Account, I authorize the Plan to issue the remaining balance from my Flex Account towards this FBA payment request. I understand I cannot collect on any out-of-pocket expenses submitted on the explanation of benefits that were over and above my Flex account balance at later date because it falls under the Plan's exclusion for partial flex reimbursement payments. By signing below, I certify that all services for which reimbursement is requested on this form were provided while I was eligible for coverage under the FBA portion of the plan and were provided to me or my dependent(s) as defined under the plan. Further, I certify that the eligible expenses have NOT been otherwise reimbursed, nor will they otherwise be reimbursed, through any other source, have not been paid (and could not have been paid) on a pre-tax basis, and have not been taken, nor intend to be taken, as a tax deduction. I understand that the Internal Revenue Code permits reimbursement only for eligible health care expenses, which means amounts paid for diagnosis, cure, mitigation, and treatment or prevention of disease. I understand that I alone am fully responsible for the sufficiency, accuracy, and truthfulness of all information relating to the claims on this form and that I am liable for payment of expenses and that if an expense is NOT eligible for reimbursement under the plan’s FBA, I am liable for payments of all related taxes on amounts paid by the Plan that relate to these expenses. By clicking Submit Form below, I am confirming that I am the authorized participant on this account. Name Your File (Optional): Click on the row to choose your claim Only claims with a service date within the past year are displayed. Please wait... Please wait while your data is loaded. If this process is taking a long time, you may have been logged out. Try logging back in. Cancel Click here to return to My Dashboard.
Wisconsin Electrical Employee Benefit Fund 2730 Dairy Drive Suite 101 Madison, WI 53718 Phone: (608) 276-9111 Phone: (800) 422-2128 Privacy Policy Contact Us