How to Submit a Claim

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Instructions for Submitting a Claim to myCafeteriaPlan


  Verify the expense is eligible for reimbursement.

  Gather your valid documentation.

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

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

  Complete a claim form if you plan to mail or fax your documentation.

  • Log into your account to download a claim form from the Tools and Support tab.
  • Be sure to sign your claim form.
  • A claim form is not needed if you submit your claim online or through the mobile app.

  Submit your claim one of four ways:

  • myCafeteriaPlan On-The-Go AppTM: Download from the App store, enter passcode, select File a Claim, and follow prompts.
  • Online: Log into your account and click the “File a Claim” link on the left-hand menu.
  • Fax: (937) 865-6502
  • Mail: myCafeteriaPlan, 432 East Pearl Street, Miamisburg, OH 45342

  Submitting documentation for a flex card transaction?

  • Do not use a claim form or file a new claim through the mobile app or online
  • Be sure you are submitting valid documentation
  • Submit documentation through the mobile app, through your online account, via fax, or in the mail

Helpful Hints

  • Use the myCafeteriaPlan On-The-Go AppTM or online claim submission features. They’re easy and convenient.
  • 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 documentation has been lost, ask your provider for another copy or contact your insurance company for an Explanation of Benefits Statement (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.

Forms and Worksheets for Submitting a Claim

The following PDF forms contain fill-able fields and automatic calculations, but must be printed and mailed or faxed after completion.  Select the form based on your benefit enrollment.

Please use only the forms that correspond to your employer’s plan as designated in the Summary Plan Description (SPD).

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.

Generic forms for Flexible Spending Accounts, Health Reimbursement Arrangements, and Qualified Transportation and Parking Plans

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).

Los formularios y hojas de cálculo en español

Formularios generales

  • Carta de necesidad médica (Formar a usted y su proveedor de atención médica ayudar a proporcionar la información que necesitamos para procesar su reclamo.)

Dependent Daycare Reimbursement Worksheet

To assist you in determining your Flexible Spending Account – FSA Dependent Daycare election, the following worksheet can be used as a guide to help determine your annual Dependent Daycare assistance costs.
Please note: qualifying expenses are those incurred for the care and well-being of your dependent(s) so that you or you and if married, you and your spouse may be gainfully employed.

Medical Expense Reimbursement Worksheet

Your Medical FSA Plan is used to help pay for uninsured, out-of-pocket medical expenses. The worksheet below helps you estimate your annual out-of-pocket medical expenses and can be a valuable tool when determining your annual election.

Medical Expenses Eligible for Reimbursement

This list is NOT comprehensive and is intended only as a guide to reimbursable expenses as governed by IRS Section 213(d).  To find out about a specific item not mentioned here, contact a myCafeteriaPlan representative or use myCafeteriaPlan’s Online Request for Information.

Please note: cosmetic services and preventative medicines (such as vitamins) are not covered unless prescribed by a physician.

Eligible OTC Items*

The following is a high level list of Over-the-Counter (OTC) items that may be eligible for purchase with FSA, HSA or HRA dollars depending on your plan.

Baby Electrolytes

  • Pedialyte

Denture Adhesives, Repair, and Cleansers

  • PoliGrip, Benzodent, Efferdent

Diabetes Testing and Aids

  • Insulin, Ascencia, One Touch, Diabetic Tussin, insulin syringes; glucose products

Diagnostic Products

  • Thermometers, blood pressure monitors, cholesterol testing

Elastics/Athletic Treatments

  • ACE, Futuro, elastic bandages, braces, hot/cold therapy, orthopedic supports, rib belts

Eye Care

  • Contact lens care solution

Family Planning

  • Pregnancy and ovulation kits

Feminine Care

  • Menstrual care products

First Aid Dressings and Supplies

  • Band-Aid, 3M Nexcare, non-sport tapes
    Hearing Aid/Medical Batteries

Incontinence Products

  • Attends, Depends, GoodNites for juvenile incontinence


  • Allergy medication, cold and flu medication, couch medication, pain relievers

Reading Glasses and Maintenance

Eligible Items*

The following is a list of potentially eligible items.

Baby/Child to Age 13

  • Lactation Consultant*
  • Lead-Based Paint Removal
  • Special Formula*
  • Tuition: Special School/Teacher for Disability or Learning Disability*
  • Well Baby/Well Child Care


  • Dental X-Ray
  • Dentures and Bridges
  • Exams and Teeth Cleaning
  • Extractions and Fillings
  • Oral Surgery
  • Orthodontia
  • Periodontal Services


  • Eye Exams
  • Eyeglasses and Contact Lenses
  • Laser Eye Surgeries
  • Prescription Sunglasses
  • Radial Keratotomy


  • Hearing Aids and Batteries
  • Hearing Exams

Lab Exams/Tests

  • Blood Tests and Metabolism Tests
  • Body Scans
  • Cardiograms
  • Laboratory fees
  • X-Rays

Medical Equipment/Supplies

  • Air Purification Equipment*
  • Arches and Orthotic Inserts
  • Contraceptive Devices
  • Crutches, Walkers, Wheel Chairs
  • Exercise Equipment*
  • Hospital Beds*
  • Medic Alert Bracelet or Necklace
  • Nebulizers
  • Orthopedic Shoes*
  • Oxygen*
  • Prosthetics
  • Syringes
  • Wigs*

Medical Procedures/Services

  • Acupuncture
  • Alcohol and Drug/Substance Abuse (inpatient treatment and outpatient care)
  • Ambulance
  • Fertility Enhancement and Treatment
  • Hair Loss Treatment*
  • Hospital Services
  • Immunization
  • In Vitro Fertilization
  • Physical Examination (not employment-related)
  • Service Animals*
  • Sterilization/Sterilization Reversal
  • Transplants (including organ donor)


  • Insulin
  • Prescription Drugs


  • Breast Pumps and Lactation Supplies
  • Lamaze Class
  • OB/GYN Exams
  • OB/GYN Prepaid Maternity Fees (reimbursable after date of birth)
  • Pre and Postnatal Treatments


  • Allergist
  • Chiropractor
  • Christian Science Practitioner*
  • Dermatologist
  • Homeopath*
  • Optometrist
  • Osteopath
  • Physician
  • Psychiatrist or Psychologist*


  • Counseling (not marital or career)*
  • Hypnosis*
  • Occupational
  • Physical
  • Smoking Cessation Programs*
  • Speech

The list above is not meant to be an all-inclusive list of potentially eligible FSA, HSA and HRA expenses, as other expenses not specifically mentioned may also qualify.  Expenses marked with an asterisk (*) are “potentially eligible expenses” that require a Note of Medical Necessity from your health care provider to qualify for reimbursement. Each plan is different; for additional information specific to your plan, check your Summary Plan Document or contact myCafeteriaPlan.

Disclaimer: Every effort has been made to present this information accurately, however, this is just a summary overview. An overview means that details, explanations, and qualifiers are left out. This information is intended only to provide general guidance.  You should not rely on it as a complete explanation of this topic. 

Cafeteria FSA Ineligible Expenses

The following is a list of ineligible items.

  • Concierge Doctor’s Fees
  • Cosmetics
  • Cosmetic surgery
  • Dancing lessons
  • Ear piercing
  • Electrolysis
  • Exercise equipment or programs
  • Facelifts
  • Fitness programs
  • Funeral expenses
  • Hair removal
  • Hair transplant
  • Herbs and herbal treatments
  • Illegal operations and treatments
  • Massage therapy to relieve stress or depression
  • Maternity clothes
  • Rogaine
  • Teeth whitening
  • Varicose vein/spider vein treatments
  • Vitamins
  • Weight-Loss programs and/or drugs



Instructions for Submitting Documentation for Receipt Requests to myCafeteriaPlan

The following instructions are for receipt requests (Flex Card transactions) only. DO NOT use a traditional (paper) claim form. Doing so may result in the expense being tagged as a duplicate (ineligible) item.

  • Assemble all supporting documentation.
    • Canceled checks, credit card receipts, and sales slips are not acceptable as documentation for eligible expenses. Cash register and/or pharmacy receipts are acceptable only when they clearly identify a prescription number or over-the-counter (OTC) item. If an OTC item is not clearly identified, the receipt with the marked or highlighted item should be accompanied by the front box cover of that item. FOR ALL OTHER EXPENSES, supporting documentation must include:
      • Provider name and address
      • Patient/Dependent name
      • Date of Service
      • Description of Service
      • Amount charged
  • An Explanation of Benefits (EOB) from an insurance company is acceptable and requires no further documentation.
  • If a pharmacy receipt has been lost: request a filled-prescription history from the pharmacist.
  • If a medical provider receipt has been lost: request an EOB from the insurance company. No other documentation is required.
  • Copy the supporting documentation and retain the originals.
  • If receipts are smaller than 8.5×11 inches, copy or tape onto an 8.5×11 inch sheet of paper – do not staple receipts to claim form or each other!
  • Submit the documentation AND receipt request together using your mobile App, online portal, mail or fax.

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