HCSA-Does a claim need to first be filed with medical insurance?

[Guest Michelle Anderson]

Does a participant in a health care spending account have to first file his medical expenses with his/her insurance before it can be paid under the flex plan?

I have an employee who does not think he needs to file his chiropractic bills with his medical insurance prior to submitting to flex. We have coverage under our medical for chiropractic care and he does have available benefits. I have asked our outside legal council their view and they feel that a medical claim must be filed first for payment or declination. Our plan document also states this.

Our employee seems to think that other companies do not require this and I would like to know if there are in fact companies that do not require the expenses to be filed with medical insurance first. For those companies that don't require medical filing I would like to know what part of the regulation that you used to implement the plan this way so I can review it.

[Lisa Hand]

Medical FSAs are for unreimbursed medical expenses. Your claim forms should have some type of statement on them that the participant signs which includes a statement that they have submitted it to their health insurance and been denied in part or in full. If it is eligible to be paid by the insurance, it must go throught his coverage first. Otherwise, there is nothing stopping the participant from claiming it through the FSA and then turning around and submitting it to the insurance and being double reimbursed. Since your plan documents clearly state the requirement and the IRC and governing regulations and publications clearly state you can not claim items for which you are eligible for reimbursement from other sources, I think your participant is either confused or has had some experience with a plan that is not administer in full compliance with the IRC.

[KIP KRAUS]

Michelle

First off, it dosen't make since not to receive the medical plan benefits first.

Secondly, most plans I've been envolved with require an EOB showing denial by the insurer, and if there is COB envolved, a copy of the secondary/primary insurer's EOB.

Lastly, if your plan requires the clzaim to be filed, case closed.