60P-6.0081. Submission of Claims for Reimbursement

(1) The participant shall submit to the Department a request which shall include the following:

(a) Social security number, name, address, work and home telephone numbers;

(b) A description of the expenses;

1. For medical expenses, the patient’s name, the dates and descriptions of services, and the expenses the participant is claiming for reimbursement;

2. For dependent day care expenses, the dependent’s name, the dates and descriptions of services, and the expenses the participant is claiming that are directly associated with the day care provided to the dependent;

(c) A statement certifying that the expenses claimed were incurred by the participant or my eligible dependent on the dates indicated, such expenses have not and will not be reimbursed by any other plan and are eligible for reimbursement, and such expenses are not eligible as deductions or credits when filing a federal income tax return;

(d) Signature of the participant, date signed, and accompanied by documentation of the expense incurred.

(2) Claims for expenses covered by insurance must include a statement from the insurer indicating the patient’s responsibility for the expense(s). Expenses shall be reimbursed only in accordance with the level of benefits in effect at the time the expense was incurred. Expenses shall be deemed incurred at the time such services are rendered.

(3) Initial requests for reimbursement for expenses incurred during a participant’s period of coverage must be postmarked or received if not mailed, at the Department no later than April 15 following the prior Plan Year.

(4) For requests filed prior to the claims filing deadline and rejected due to lack of proper documentation, such documentation must be submitted, within the claims filing run-out period.

Specific Authority 110.161(5) FS. Law Implemented 110.161 FS. History–New 8-26-96, Repromulgated 4-25-02.