The following forms and instructions are for traditional (paper) claims only. Visit these links for information on Flex Card and Receipt Requests.

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• Submit a Claim
• Helpful Hints
• Fillable Forms
• Worksheets

Instructions for Submitting a Claim to myCafeteriaPlan

Verify the expense is eligible for reimbursement

• Review the IRS rules listed in your Summary Plan Description (SPD). To view your SPD, login to your account by clicking the Login Button found on your homepage and click the “Forms” link on left-hand menu
• View the list of Eligible Expenses
• Contact myCafeteriaPlan to ask about a specific item

Gather your valid receipts

• Canceled checks and credit card receipts are not valid receipts. Valid receipts should include:
• Provider Name & Address
• Patient Name
• Date of Service
• Service Description
• Amount Charged
• For Daycare Expenses Only
• In addition to the information required for valid receipts, daycare receipts must include your provider’s Taxpayer Identification Number (TIN) or Social Security Number (SSN).
• If your provider signs the claim form, no other receipts are needed (the claim form turns into your receipt).
• If you are married, both you and your spouse must be employed to qualify for the daycare pre-tax benefit.
• An Explanation of Benefits (EOB) from an insurance company is a valid receipt.

Copy your receipts and keep originals for your personal tax records.

Complete a claim form if you plan to mail, fax or email your receipts.

• Log into your account for your customized claim forms.
• Be sure to sign your claim form.
• Claim form is not needed if you submit your claim online.

Submit your claim one of four ways:

• Online: Log into your account and click the “Submit Claim” link on left-hand menu.
• Email: Located on the Contact Us page
• Fax: Located on the Contact Us page
• Mail: Located on the Contact Us page

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Helpful Hints

• Use the online claim submission feature. It’s easy and convenient.
• If you email your claim, try to keep the attachment size as small as possible.
• If you mail your claim, please tape small receipt copies onto an 8.5×11 inch sheet of paper. Please do not submit any stapled items.
• If a receipt has been lost, ask your provider for another copy or contact your insurance company for an EOB.
• If you have lots of prescriptions, ask your provider for a prescription history. You’ll never have to worry about losing those little receipts again.
• If you run out of room on your claim form, please use additional claim forms and submit separately.

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 myCafeteriaPlan Fillable Claim Forms

The following PDF forms contain fill-able fields and automatic calculations, but must be printed and mailed or faxed after completion.

Note to Participants: Use only the forms that correspond to your employer’s plan as designated in the Summary Plan Description (SPD).

•  (Standard form for medical and dependent care claim submissions)
• FSA Medical Only Claim Form (Standard form for only medical claim submissions)
• Health Reimbursement Arrangement (HRA) Claim Form
• Individual Premium Reimbursement Claim Form
• Orthodontic Claim Form (Schedules orthodontic treatments for automatic processing and reimbursement without subsequent re-submission of the same claim)
• Transportation Reimbursement Claim Form

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myCafeteriaPlan Flexible Spending Account (FSA) Worksheets

The following PDF forms contain fill-able fields and automatic calculations, but must be printed in order to be retained as a record. Use these forms to help determine annual election amounts.

• FSA Dependent Care Worksheet (Calculates annual dependent care expenses)
• FSA Medical Worksheet (Calculates annual medical expenses)

Please note Adobe Acrobat® Reader® is needed to view these PDF documents. If you do not already have this program you may click on the icon below for a free download.

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