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Submitting Claims

How to Get Reimbursed for Expenses

A Request for Reimbursement Form is used to submit a reimbursement claim. The expenses listed on the form must be incurred by you, your spouse, or dependent during the coverage period and the dates of service must be noted on the reimbursement form.

After you complete the Request for Reimbursement Form, submit it to CONEXIS along with appropriate supporting documentation.

Supporting Documentation

  • For office visits: Your health plan's Explanation of Benefits (EOB) statement or an itemized receipt or bill from the provider that includes the patient's name, a description of the service, the original date of service and your portion of the charge.
  • For prescription drugs: A pharmacy statement or receipt from your pharmacy including the patient's name, the Rx number, the name of the drug, the date the prescription was filled, and the amount.
  • For over-the-counter medicines: A written or electronic OTC prescription along with an itemized cash register receipt that includes the merchant name, name of the OTC medicine or drug, purchase date, and amount, OR a printed pharmacy statement or receipt from a pharmacy that includes the patient's name, the Rx number, the date the prescription was filled, and the amount.
  • For over-the-counter health care-related products: An itemized cash register receipt with the merchant name, name of the item/product, date, and amount.

Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

For some expenses, a Medical Determination Form from a doctor may be required. See our Eligible Health FSA Expenses page for more information.

Find a Request for Reimbursement Form and a Medical Determination Form by logging in to your online account.

Submitting Reimbursement Requests

You can submit your reimbursement requests three ways.

  • Online: Log in to your online account, download and complete a reimbursement form, and then upload your supporting documentation. You will need access to a scanner to do this.
  • Fax: Submit your completed reimbursement form and supporting documentation using the fax number listed on the form.
  • Mail: Send in your completed reimbursement form and copies of your supporting documentation using the address noted on your form.