How do I request payment from either my Medical or Dependent Care “Spending Account”?

      1) Complete Claim Form.

      2) Attach Receipts.

      3) Make a Copy of Claim and Receipts for your records.

      4) Mail or Fax Claim to BCI Administrators, Inc.

STEP 1:

  Once you have an expense that qualifies for reimbursement, fill out a “Flexible Benefit Claim for Reimbursement” Form.  Make sure the Form is completely and accurately filled out.  BCI Administrators, Inc. cannot issue a reimbursements unless the Form is complete and accurate.  Your signature on the Form will confirm that the expenses you are requesting payment for are valid under the reimbursement account plan. An eligible expense is an uninsured, out-of-pocket expense that the IRS allows as a deductible medical expense.  In addition, you may visit the IRS web site (link below) for a list of potentially covered expenses. IRS Publication 502 listing This link is for informational purposes only. Check with your Human Resources Department or review your Summary Plan Description (SPD) for more information as not all items may be reimbursable under your plan.  You may also contact a BCI representative at (248) 626-8896, or outside the 248 area code at (800) 757-7204, for assistance in clarifying an eligible expense.

STEP 2:

  Attach your PROOF OF THE EXPENSE to the REQUEST FOR REIMBURSEMENT form.  Acceptable forms of proof that you have incurred the expense include:

·          Photocopies of or, actual canceled checks (Allowable for Dependent Care reimbursement only.)

·         Account Statements which indicate the name of the provider, date of service, charges and payment                  amounts, and  indication that payment was made.

·         Receipts, which indicate the provider’s name, date of service and payment amount.

·         Explanation of Benefits (EOB’s) from your insurance carrier(s).  This is the only acceptable proof for items such as deductibles and co-payments, or any item that is at least partially covered by your health insurance plan.

STEP 3:

  Be sure to KEEP COPIES of your REQUEST FOR REIMBURSEMENT (and PROOF) for your records.

STEP 4:

 Mail or Fax your REQUEST FOR REIMBURSEMENT Form and PROOF to:

        BCI Administrators, Inc.

        P.O. Box 251568

        West Bloomfield, MI  48325-1568

        FAX: (248) 626-8185

Last modified:11/20/2006