6696R1 Pg 2 4.1.04 790.3249 6696 Claimreim
User Manual: 790.3249
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lex Claims De
P.O. Box 1021
new address Em
Patient Name Name of Provider Description of Service Amount Requested
Total Amount Requested:
Total Amount Requested:
Day Care Provider's Original Signature X
Employee Signature Date
Note: OxfordFlex employer groups and members may want to consult a tax advisor regarding Section 125 qualified cafeteria plans and other reimbursement accounts
permitted by the Internal Revenue Code. The employer, not Oxford Benefit Management (OBM), shall remain the group’s fiduciary for the group's health benefit plan.
Complete this form and attach an itemized statement from your day care provider or have your provider complete the information below. IRS
Regulations allow payment for services that have already been provided, not for services to be provided in the future. IRS regulations require the
provider to furnish their name, address and tax identification number (or SS#). If your day care provider completes and signs this form below, no
other itemized statement is necessary.
I certify that I have actually incurred these expenses. I certify that I have not been reimbursed for the above expense(s) and I will not seek reimbursement under any other
plan covering health benefits. I understand that any amounts reimbursed may not be claimed on my or my spouse's personal income tax for the purpose of income or tax
reduction. If I obtain reimbursement for these expenses which are later determined to be ineligible expenses as defined under the Internal Revenue Code for Section 125
qualified cafeteria plans, I agree to reimburse my OxfordFlex account as directed by my employer. The amount credited to my OxfordFlex plan for any Plan Year shall be
used only to reimburse me for qualifying OxfordFlex Healthcare and OxfordFlex Dependent Care expenses incurred during such Plan Year while I was a Member, and only
if I apply for reimbursement on or before the 90th day following the close of the Plan Year.
Dates of Service
Age Provider TIN/SSN
4. Claim Certification
OxfordFlex SM Claim Reimbursement Form (OxfordFlex SM Healthcare /OxfordFlex SM Dependent Care )
1. Employee Information
2. OxfordFlex Healthcare
3. OxfordFlex Dependent Care
Please complete this form in its entirety and attach an itemized statement, insurance explanation of benefits or receipt. Please review the
instructions prior to completing this form.
Cost of Service/
Relation to Employee
Date of Service
MS-03-1639 6696 R1
OxfordFlex Claim Submission Guidelines
To ensure you are provided the best service and receive timely payment of your OxfordFlex claims, please follow the short list of guidelines and
checklist we have created for you. The steps below highlight the information and documentation required for us to process your claim quickly
without requesting additional information.
OxfordFlex Healthcare Claims
1. If you have medical, dental or vision insurance, all
expenses must be submitted to your insurance company
before submitting for reimbursement.
2. When submitting a claim for reimbursement that is partially
covered by your medical or dental insurance carrier (Oxford
Health Plans or other carrier), you must:
Complete the claim form and include the Explanation of Benefits
(EOB), which indicates the out-of-pocket expense amount.
3. When submitting a claim for reimbursement for which no
portion of the expense is covered by your medical or
dental insurance carrier (Oxford Health Plans or other
carrier), you must:
Provide an itemized statement that includes:
- the provider’s name and address
- provider’s tax identification number (if applicable)
- the date(s) of service
- description of service (balance due
statements are not sufficient)
- the dollar amount charged
4. Balance forward statements, canceled checks, credit card
receipts are not acceptable.
5. When requesting reimbursement for prescription drugs,
medical equipment, vision services or specialized therapy
you must include the following:
Prescription medication - Please provide a receipt, which
provides the patient’s name, the prescription number, the
prescription name, and dollar amount.
Medical equipment - A letter/note from the physician
prescribing the equipment as treatment for a specific condition,
(e.g., glucose monitor for diabetes).
Vision services - An itemized receipt for glasses and/or
contact lenses. Claims for enzyme cleaners and lens solutions
must be accompanied by a receipt identifying the brand name or
type of item purchased.
Specialized therapy - A letter/note from your physician
prescribing the therapy as treatment for a specific medical
OxfordFlex Dependent Care Claims
Claims for dependent care must be submitted with a receipt or
statement from the daycare provider that substantiates the request
for reimbursement. If you do not have enough contributions to cover
the full expense, we will provide additional reimbursement once addi-
tional contributions are made to your account.
Please provide an itemized statement that includes:
- the name of the provider
- the address of the provider
- Social Security Number or Tax Identification
number of the provider
- the dates of service
- the amount claimed
Examples of documentation:
1. Commercially prepared/business-generated statement or receipt
(commonly used by larger daycare facilities)
2. General receipt pad (provider signature recommended)
3. Handwritten or typed note (this can be generated by the provider
EXCEPTION: If care if provided by a relative, your canceled check
may be used as documentation: however, if you pay the relative in
cash, you must include a receipt. PAYMENT TO RELATIVE should be
indicated on each claim form submitted.
❑ Include your name
❑ Include your Social Security Number
❑ List expenses for each family member (Dependent Care
claims require the name and age of each dependent)
❑ Attach all required documentation for each expense
❑ Indicate your requested reimbursement amount if
different from your receipt totals
❑ Sign your claim form
Checklist for submitting your OxfordFlex Claim
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