Submitting A Claim

Dependent Day Care FSA and Healthcare FSA claims not paid for with the FSA Debit Card can be filed anytime with Benesyst. 

Online Claim Wizard

The fastest and easiest way to submit your claim is using the Online Claim Wizard. It allows you to submit your FSA and/or HRA expense information online and gives you the option of uploading your scanned documentation or printing a bar-coded cover sheet to fax your supporting documentation to Benesyst.

You can enter multiple expenses all in one claim, and you can save your work and return at any time!

You can upload supporting documentation online (documents should be in .JPG, .TIFF or PDF format and must be 8MB or smaller) and the system allows you to view and review your documents before submitting your claim.

If you do not upload documentation, you will be presented with a Fax Cover Sheet to print and fax along with your documentation to (800) 310-8279 after you submit your claim.

Toll Free Fax

If not using the Online Claim Wizard, to be reimbursed for any eligible expenses (for both Health Care and Dependent Day Care FSAs), you must mail or fax (not both) a completed Easy Reimbursement Request form along with IRS required documentation. 

  • Fax toll-free any time to: (800) 310-8279
  • To expedite faxed claim processing – please submit copies of receipts on 8x11 paper. Do not highlight the expense on the receipt as this can block the fax transmission. 
  • If you have signed up for email alerts, you will receive email confirmation when your fax is received.

Claims in progress

The status of your faxed and online submitted claims will be available on the Spending Account Services Dashboard via logging into your online account. Log in here.

Health Care Claim Form

You can submit claims using the Online Claim Wizard, or download and print a new form for each claim (due to the design of the form, do not photocopy). 

Dependent Day Care Claim Form

You can submit claims using the Online Claim Wizard, or download and print a new form for each claim (due to the design of the form, do not photocopy).

Submitting the Necessary Documentation

FSA Health Care Claims Acceptable Documentation:

  • An itemized provider statement or receipt that provides: The date of service, the description of services received and the amount owed after any insurance benefits have been paid to the provider
  • Explanation of Benefits (EOB) from the insurance company

Please note that certain expenses may require additional documentation. For Orthodontia documentation please click here.

Documentation not acceptable for FSA Health Care Claims

  • Credit card receipts/statements
  • Cancelled/copy of personal check
  • Receipts that show only the amount of payment made
  • Statements with estimated insurance amounts expected or a balance forward

FSA Dependent Day Care Claims Acceptable Documentation:

Dependent Day Care Claim documentation must include the following information:

  • The name and tax ID of the day care provider.
  • The dates service was provided.
  • A description of services provided.
  • The cost of services provided.

You can have your provider sign the FSA Dependent Day Care Easy Reimbursement Request form. By submitting a completed form, signed by your day care provider, your claim will be in compliance. If your provider completes and signs the reimbursement section (complete with their tax ID), separate billing and receipts are not needed.

The expenses should be correlated with the service dates, not payment dates.

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