Tips for Submitting Claims
You need to submit a new claim for each reimbursement you wish to receive. Claims submitted for future payment dates will be denied and will require a new claim after the scheduled payment date.
Over-the-Counter (OTC) Expenses
- The IRS requires that a merchant-generated receipt or statement be provided as supporting documentation for each item purchased. The receipt or statement must include all the following pieces of information, which cannot be handwritten on the receipt or statement:
- Date of purchase
- Name of OTC item
- Amount paid for OTC item
- The item must be purchased in a reasonable quantity. Items must be purchased with the intent that they will be used within the current calendar year. For example, it would not be acceptable to purchase 48 bottles of aspirin at the end of the year.
- If you have a vision benefit plan, the provider receipt must include indication of the vision benefit or discount (not handwritten or an estimate).
- If the expense is covered by your insurance plan, include a copy of the Explanation of Benefits (EOB) from your vision benefit.
- The documentation submitted with your claim must indicate when the service was received, not billed.
- Balance forward or account payment statements will not be accepted as documentation.
- If the provider statement indicates an estimate of coverage submitted to dental plan or payment pending, include a copy of the Explanation of Benefits, (EOB) from your dental plan. Your claim will not be processed until the EOB is received.
Orthodontia treatment programs can take several years to complete, meaning you may be making payments and submitting claims over a longer period of time. For fastest processing, submit a claim and upload the following documentation.
Orthodontic contract which includes:
- The patient’s name
- The date the services began
- The length of the treatment
- Any discounts you receive
- Insurance benefit, if applicable
- The total orthodontic contract amount due
- Payment option selected (see below)
If you have a lump sum payment plan where the contract is paid in one or two large payments:
- Make sure the dollar amount you’re requesting matches the orthodontia contract.
- If the dollar amount submitted does not match your orthodontia contract, send a receipt indicating orthodontia payment and that it is non-refundable.
If you have a payment plan where payments are made over a period of time, such as monthly or quarterly:
Include at least one of the following items (must indicate orthodontic services and name of the service provider):
- A copy of the coupon book payment slip with the due date
- A copy of a bill showing the amount due
- A copy of a paid receipt — not a canceled check
- A copy of your orthodontist’s book showing the payment
Expenses not covered
- Late payment fees
- Fees for missed appointments
- Interest payments for services charged to a credit card or other financial agreements.
Frequently Asked Questions
- My claim or reimbursement request was denied. What can I do?
- After receiving a complete or partial denial of a claim, we recommend you contact our Customer Service department for help in understanding what can be done to get your claim reimbursed.If the claim is still being denied after working with us, you can appeal the decision by filling out an Appeal Form. We recommend you work with your employer or benefits administrator to make sure you have complete and accurate information when making your appeal. Capital Blue Cross will perform a full and fair review of your claim and provide you with written notice of the decision within 30 days of receiving your appeal request.
- You can also designate another person to manage the appeal process on your behalf by completing an Authorization for Release of Information for them.
- Do I need to keep receipts for my debit card purchases?
- Yes. While most expenses are verified at the time of purchase, there are some where you may need to submit documentation to Capital Blue Cross to prove they are eligible to be reimbursed from the account. Failure to respond to a request for proof the expense is eligible can lead to your debit card being suspended. In addition, the IRS requires you to retain proof for up to seven (7) years, in the event you are audited.
- What if I have another account paired with my HSA?
- When actively contributing to an HSA, the following limitations may apply (please see your Summary Plan Description for details):
HSA + FSA: The FSA is limited to vision and dental expenses until you have met your IRS minimum deductible with your insurance.