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How do I use the online image of my claim to figure out what was not approved?

If you receive notice by email or letter that your claim was not approved, you can log into your ProBenefits account online and take a look at an image of the claim you submitted, which will have some markup from us indicating which parts had problems. This information, plus the information contained in the notice you received, should help you figure out why your claim was denied.

First, you can take a look at the claim form image.

If part of the claim is approved, it will have a green "Approved" stamp, and a yellow box. Inside the yellow box will be the amount that we approved, and the dates of service for the approved portion (as in the example above). If the whole claim was denied, it will have a red "Denied" stamp. If the approved portion of the claim was for dependent care expenses, it will have an "Approved Dependent Care" stamp. All of these stamps will be accompanied by the date the claim was processed. Examples of those stamps:

Below are some of the common notes you'll find stamped on the image of your claim, along with the corresponding information that you would receive in your emailed or mailed notification, and some further explanation. If you have questions about any denial, please contact us for more information!

 


 

On your Claim Form:

On your Claim Confirmation: "The claim we received had missing or partial pages.  Please resubmit this entire claim along with a copy of this correspondence.  Please indicate on your documentation that this is a resubmission of a partial claim."

What this means: All of the pages may not have come through on your fax - compare the online image of your claim with your copy to see what we're missing.

 


 

On your receipt:

On your Claim Confirmation: "From the documentation you submitted, we are unable to determine what portion of the expense is the participant's responsibility. If you are responsible for more than the amount we have approved, please submit additional documentation (such as the Explanation of Benefits, or EOB, from your insurance company) clarifying your portion of the expense."

What this means: We frequently see this problem with receipts from a dental office. Often they show the total cost of the procedure, and indicate that a patient has insurance, but don't indicate how much of the procedure is actually the patient's responsibility to pay. Look for an EOB on your insurance company's website if the provider's office cannot give you adequate documentation.

 


 

On your receipt:

On your Claim Confirmation (one of these):
"The date(s) of service are in a prior plan year. Your claim was submitted after the 90-day runout period specified in your employer's Plan Documents for submitting claims from that plan year."

"Dates of service included in your claim were in a prior plan year. Claims equal to the prior year's election have already been submitted, so you do not need to submit any further claims for the prior plan year."

"The date of service shown on your receipt is BEFORE the date you became eligible under the Flex Plan. All expenses must be incurred while you are an active participant in the plan."

"The date(s) of service are after your termination of plan participation. For an expense to be eligible, it must be incurred while you are an active participant in the plan."

What this means: The Date of Service is crucial in determining the eligibility of an expense, because we have to ascertain that the service was performed during your plan year. If the service was performed before you became eligible for the plan, or after you terminated participation in the plan, it can't be approved. And if the expense was during a prior plan year in which you had an active FSA, it can only be approved if you still have money in that plan year and if the date you submit it is within the 90-day runout period after the end of the plan year.

 


 

On your receipt:

On your Claim Confirmation (one or both of these):
"Though the type of expense submitted is eligible, the documentation does not show a date of service. You may resubmit this claim with the appropriate documentation."

"The expense may be eligible for reimbursement; however, based on the receipt provided, we couldn't determine the nature of the product or service. You may resubmit this claim with additional detail."

What this means: Be sure your receipt clearly indicates the Date of Service (not the date of payment!) and the type of expense. For example, a receipt that just indicates you paid $304 toward your account balance on June 11 does not give us the information we need. A receipt that indicates that you had an Office Visit with Region Medical Specialists on June 14, 2014 and owed a co-pay of $20 has all the information we need.

 


 

On your receipt:

On your Claim Confirmation: "The enclosed expenses are not eligible for reimbursement. A list of eligible expenses is on our web site at www.ProBenefits.com. From the 'Participants' menu, choose 'Eligible Expenses.'"

What this means: Unfortunately, the expense you have submitted for reimbursement is not an FSA-eligible expense. There are plenty of other expenses you can submit for reimbursement though!

 


 

On your receipt:

On your Claim Confirmation: "Amounts expended for food, vitamins, nutritional and herbal supplements, and natural medicines will be reimbursable only if the substance is prescribed by a physician to treat a specific medical condition. A doctor's certification is required and must clearly state the supplement name AND the medical condition. This note is valid for your current plan year only and will need to be renewed."

What this means: You can submit the claim again with a note from your doctor, and we can approve the expense.

 


 

On your receipt:

On your Claim Confirmation: "Credit/debit card slips, copies of checks, bank statements and credit card statements do not meet the requirements for proper documentation. Please obtain a document from the provider showing the date of service, the type of service, and the expenseincurred. You may resubmit this claim with the appropriate documentation."

What this means: Unfortunately, the IRS does not allow us to use credit/debit card slips, copies of checks, bank statements, etc. for documentation, because they generally do not contain the information we need. The exception to this is detailed receipts from retail merchants that indicate the items you purchased and the date you purchased them.

 


 

On your receipt:

On your Claim Confirmation: "Orthodontia services may be reimbursed either as a one-time lump-sum payment, or as payments toward a contracted payment plan. Additional information is required prior to reimbursement. This information can usually be found on the financial agreement or contract that you may have entered into with the provider and should include: Name of provider and patient, total cost of treatment, start date and estimated end date of the treatment. For detailed information about what is required for orthodontia reimbursement, please visit www.ProBenefits.com, select "Get a Form", and then choose "Orthodontia Reimbursement." You may also click on this link or paste it into your web browser: http://www.probenefits.com/forms/Ortho.pdf"

What this means: Please read over the information online about orthodontia reimbursement carefully. Often all we need in addition to what you have already submitted is a copy of your financial agreement with your provider.