Year-End Claim Filing
Reminder
Your Flexible Spending Account (FSA) plan year will be ending soon and we want to remind you to file any outstanding claims
as soon as possible because any unused balance in your account will be forfeited. Please note that your plan includes a run-
out period giving you additional time to file claims that were incurred during the plan year. Typically, the run-out period is
90 days following the end of your plan year but be sure to verify with your employer. In this example, you would have 90
days following the end of the plan year to file claims incurred during the plan year.
Please remember that the IRS requires appropriate documentation when submitting a claim. All medical,
dental and vision claims must include the following:
A completed and signed claim form.
Either an Explanation of Benefits (EOB) statement from your insurance company OR an itemized statement from the
provider showing provider's name, address, patient name, date and description of service and amount paid.
Submitting a Claim to PayFlex®
File a claim online
Go to HealthHub.com, click on Employee Account Login and enter your username and password, then click Login.
Select File a Claim under Quick Links and follow these four steps:
Step 1 - Enter your claim information; type of expense, date of expense, and amount of expense. To add additional claims,
select Add Another Claim. Once you have entered in all of your claims, click Next.
Step 2 – Confirm all expense details, then click Next.
Step 3 - You will have the option to “FAX” or “UPLOAD” your supporting documentation.
o If you select “UPLOAD,” your documentation must be in PDF Format.
o If you select “FAX”, click Create Coversheet, then print and sign the form and fax the claim and itemized receipts to
866.932.2567. The itemized receipts (documentation) must include the provider name/address, date the service was
provided, description of the type of service provided, and the dollar amount.
If you are enrolled in eNotify, you will receive an email from PayFlex notifying you when your claim has been processed.
File a claim via fax or mail
Go to HealthHub.com, click on My HealthHub Resources, then select Administrative Forms and click on Health and
Dependent Care Claim Form.
Print form; complete all fields, sign and date. Then submit the completed claim form and itemized receipts to PayFlex via
FAX: 402.231.4310 (OR) MAIL: PayFlex Systems USA, Inc.
P.O. Box 3039
Omaha, NE 68103-3039