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P O BOX 7777, LANCASTER, PA 17604-7777. PHONE 717-581-1300 1-800- 433-3746. FAX 717-581-8379 www.significabenefits.com. Updated 8/2010.

How to fill out health reimbursement arrangement claim

1. To fill out a health reimbursement arrangement (HRA) claim, start by obtaining the necessary claim form from your employer or insurance provider.
2. Carefully read through the instructions and requirements listed on the form to ensure you provide accurate and complete information.
3. Fill in the personal details section, including your name, address, and contact information.
4. Provide your insurance or policy information, including the HRA account number and any related plan details.
5. Document the date of service or purchase for each item or service being claimed.
6. Describe the nature of the expense, such as a medical procedure, prescription medication, or eligible healthcare service.
7. Attach any necessary supporting documentation, such as receipts, invoices, or Explanation of Benefits (EOB) forms from your insurance provider.
8. Indicate the total amount being claimed for each expense and calculate the overall total.
9. Review the completed form to ensure accuracy and double-check all the provided information.
10. Sign and date the form, acknowledging that the information provided is true and accurate to the best of your knowledge.

Who needs a health reimbursement arrangement claim?

1. Any individual who has a health reimbursement arrangement as part of their employee benefits package may need to submit an HRA claim.
2. HRA claims are typically filed by employees who have incurred eligible healthcare expenses and wish to be reimbursed from their HRA account.
3. It is important to consult the specific guidelines and requirements of your HRA plan to determine if you are eligible to file a claim and what expenses are covered under your plan.

For pdfFiller’s FAQs

What is health reimbursement arrangement claim?

A health reimbursement arrangement claim is a request for reimbursement of medical expenses paid by an individual and eligible for reimbursement through an employer-sponsored HRA plan.

Who is required to file health reimbursement arrangement claim?

Employees who have incurred eligible medical expenses and are covered under a health reimbursement arrangement plan are required to file a claim for reimbursement.

How to fill out health reimbursement arrangement claim?

To fill out a health reimbursement arrangement claim, individuals must provide documentation of the medical expenses incurred, including receipts and a claim form provided by the employer or HRA administrator.

What is the purpose of health reimbursement arrangement claim?

The purpose of a health reimbursement arrangement claim is to request reimbursement for eligible medical expenses paid by an individual that are covered under an employer-sponsored HRA plan.

What information must be reported on health reimbursement arrangement claim?

The information required on a health reimbursement arrangement claim typically includes the individual's name, date of service, description of the medical expense, amount paid, and any supporting documentation such as receipts.

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