How to Submit a Claim for Reimbursement

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

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.