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FSA Health Care Claims Process


A signed and dated claim form should be accompanied by one of the following:
  • An Explanation of Benefits (EOB) from your insurance carrier showing the date of service and out-of-pocket expense(s). If the EOB indicates the procedure is not covered by your health insurance plan, you may be required to submit an itemized statement from the provider.
  • For expenses not covered by insurance, an itemized statement from the service provider. The itemized statement should include the patient’s name, date(s) of service, procedure description(s), provider name and the charge(s) for the service. Account balance statements, balance forward statements, cancelled checks, cash register receipts and credit card receipts are not acceptable third-party documentation (see below for special rule regarding cash register receipts for eligible over-the-counter medications). In some cases, a letter of medical necessity from a medical practitioner may be required.
  • For prescription drugs, a pharmacy statement including the name of the pharmacy, patient’s name, date of fill, cost, Rx number and name of the drug.
  • An itemized cash register receipt for eligible over-the-counter medications. The name of the medication and the purchase date must be on the receipt.
  • Dual-purpose items are not reimbursable without a letter of medical necessity from a medical practitioner. For a list of dual-purpose items go to https://www.conexis.org/solutions/overthecounter_EE.asp .



Choose a letter to skip to that section: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Expense Description Eligible? Substantiation Processing Notes
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A
Acne treatments (e.g. Clearasil, Proactiv) Yes Standard Must be used to treat specific medical condition
Acupuncture Yes Standard  
Adoption, medical expenses Potentially Standard + legal documents pertaining to adoption For medical expenses incurred before an adoption is finalized, if the child was a legal dependent when services were provided
Alcohol & drug rehab Yes Standard  
Allergy medicine Yes Standard  
Allergy products & home improvements to treat severe allergies Potentially Standard + letter of medical necessity Examples of eligible expenses include: special vacuum cleaners, electro-static air purifiers, pillows and mattresses to alleviate certain allergies, etc. If the product would be owned without the allergy, then the expense is not considered eligible. See capital expenses
Alternative healers, dietary substitutes and drugs and medicines Potentially Standard + letter of medical necessity  
Ambulance transport Yes Standard  
Antacid Yes Standard  
Antihistamine Yes Standard  
Artificial limbs and teeth Yes Standard  
Aspirin Yes Standard  
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B
Bactine Yes Standard  
Bandages Yes Standard  
Batteries for durable medical equipment Yes Standard Participant must note usage of batteries on receipt
Birth control pills Yes Standard  
Blood pressure monitoring devices Yes Standard  
Blood sugar test kit and test strips Yes Standard  
Body scan / diagnostic testing Yes Standard  
Braille books and magazines Potentially Standard + letter of medical necessity If for the visually-impaired person, only the amount above the cost of regular printed material is reimbursable
Breast reconstruction surgery following mastectomy Yes Standard  
Burn garment Yes Standard  
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C
Calamine lotion Yes Standard  
Capital expenses Potentially Standard + letter of medical necessity The primary purpose of the expenditure must be for the medical care of the taxpayer, spouse, or dependent. The following information must be provided to determine eligibility:
      1. A letter and/or prescription from a physician citing the medical necessity
      2. A written certification that states the item is for the patient's individual use, or the percentage of use in relation to other members of the household
      3. Third-party appraisal of the participant's home to substantiate the difference between the cost of capital expenditure and the increase in value to the participant's home (the cost of the appraisal is not reimbursable)
Carpal tunnel wrist supports Yes Standard  
Cayenne pepper Potentially Standard + letter of medical necessity  
Chelation (EDTA) therapy Yes Standard + letter of medical necessity Only if used to treat a medical condition such as lead poisoning
Childbirth classes Yes Standard See Lamaze and Personal-only expenses
Chiropractors Yes Standard  
Chondroitin Potentially Standard + letter of medical necessity Only if used to treat a medical condition
Christian Science practitioners Yes Standard  
Circumcision Yes Standard  
Claritin Yes Standard  
COBRA premiums No N/A  
Coinsurance and deductibles Yes Standard  
Cold medicines Yes Standard  
Cold packs Yes Standard  
Cologne No N/A  
Condoms Yes Standard  
Contact lenses, materials and equipment Yes Standard  
Contraceptives Yes Standard  
Controlled substances in violation of federal law No N/A  
Cosmetics No N/A  
Cosmetic rx's No N/A  
CPR classes Potentially Standard + letter of medical necessity  
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D
Decongestants Yes Standard  
Dental visits (non-cosmetic) Yes Standard Cosmetic dental procedures are not eligible
Dentures Yes Standard  
Deodorant No N/A  
Diabetic supplies Yes Standard  
Diagnostic services Yes Standard  
Diapers or diaper service for newborns No N/A  
Diaper rash ointments and creams Yes Standard  
Diarrhea medicine Yes Standard  
Dietary supplements Potentially Standard + letter of medical necessity  
Diet foods No N/A Not unless recommended by a physician
Disabled dependent's qualified medical expenses Yes Standard  
DNA collection & storage No N/A  
Doula (birthing coach) Potentially Standard + letter of medical necessity  
Drug addiction treatment Yes Standard  
Drug overdose, treatment of Yes Standard  
Dual-purpose expenses (items that have both a medical and general/personal/cosmetic purpose) Potentially Standard + letter of medical necessity  
Durable medical equipment Potentially Standard + letter of medical necessity Crutches, wheelchairs, nebulizers, etc.
Dyslexia Potentially Standard + letter of medical necessity  
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E
Ear piercing No N/A  
Ear plugs Potentially Standard + letter of medical necessity  
Egg donor fees Yes Standard  
Eggs and embryos storage fees Yes Standard Only temporary storage is eligible
Electrolysis or hair removal No N/A  
Elevator Potentially Standard + letter of medical necessity See Capital Expenses
Exercise equipment or programs Potentially Standard + letter of medical necessity Not unless recommended by a physician to treat a specific medical condition and the equipment would not otherwise be purchased but for treatment of the condition
Expenses reimbursed by a health reimbursement account (HRA) No N/A  
Eye examinations, eyeglasses, equipment and materials Yes Standard  
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F
Face creams and moisturizers No N/A  
Face lifts No N/A  
Family counseling Potentially Standard + letter of medical necessity Not unless recommended to treat a mental disorder
Feminine hygiene products (tampons, etc.) No N/A  
Fertility treatments Yes Standard  
Fiber supplements Potentially Standard + letter of medical necessity Only if recommended by a physician
First aid cream Yes Standard  
First aid kits Yes Standard  
Flu shots Yes Standard  
Fluoridation device Yes Standard  
Foods Potentially Standard + letter of medical necessity See Special foods; Meals; Alternative healers, dietary substitutes; Drugs and medicines; and Personal-only expenses
Founder's fee No N/A  
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G
Gauze pads Yes Standard  
Genetic testing Potentially Standard + letter of medical necessity If ordered for medical care
GIFT Yes Standard  
Glucosamine Potentially Standard + letter of medical necessity See Dual-purpose expenses
Glucose monitoring equipment Yes Standard  
Glucose tablets Yes Standard  
Guide dog; other animal aide Potentially Standard + letter of medical necessity  
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H
Hair colorants No N/A  
Hair removal and transplants No N/A  
Hand lotion No N/A  
Health club dues and fees Potentially Standard + letter of medical necessity Not unless recommended by a physician to treat a specific medical condition and expense would not otherwise be incurred but for treatment of the condition. Expenses incurred for general health purposes are not eligible.
Health institute fees Potentially Standard + letter of medical necessity Not unless recommended by a physician
Hearing aids Yes Standard  
Hemorrhoid treatments Yes Standard  
Herbs Potentially Standard + letter of medical necessity  
Hormone replacement therapy (HRT) Potentially Standard + letter of medical necessity Only if used to treat a medical condition
Hospital services Yes Standard  
Hot packs Yes Standard  
Household help No N/A  
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I, J, K
Illegal operations and treatments No N/A  
Immunizations Yes Standard  
Inclinator Yes Standard  
Incontinence supplies Yes Standard  
Insect bite creams and ointments Yes Standard  
Insulin Yes Standard  
Insurance premiums No N/A  
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L
Laboratory fees Yes Standard  
Lactaid Yes Standard  
Lactation consultant Potentially Standard + letter of medical necessity  
Lamaze classes Yes Standard Only the portion of the class covering the birthing process is covered
Language training Potentially Standard + letter of medical necessity  
Lasik eye surgery Yes Standard  
Laxatives Yes Standard  
Lead-based paint removal Potentially Standard + letter of medical necessity Eligible if done to prevent a child who has or had lead poisoning from eating the paint. The wall surface must be within the child's reach
Learning disability Potentially Standard + letter of medical necessity If for a child with dyslexia or a disabled child. But school fees for regular schooling normally don't qualify
Lifetime care-advance payments No N/A  
Lipsticks No N/A
Liquid adhesive for small cuts Yes Standard  
Lodging at a hospital or similar institution (patient only) Yes Standard  
Lodging of a companion Yes Standard If accompanying a patient for medical treatment
Lodging not at a hospital or similar institution Yes Standard Up to $50 per night if the lodging is primarily for and essential to medical care. The service must be provided by a physician in a licensed hospital or medical care facility equivalent to a licensed hospital. An additional $50 per night may be reimbursable for a parent or companion who must accompany the patient
Lodging while attending a medical conference No N/A  
Long-term care premiums No N/A  
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M
Make-up No N/A  
Marijuana or other controlled substances in violation of federal law No N/A  
Marriage counseling No N/A  
Massage therapy Potentially Standard + letter of medical necessity  
Mastectomy-related special bras Potentially Standard + letter of medical necessity Not unless recommended to treat a mental disorder
Maternity clothes No N/A  
Meals at a hospital or similar institution (Patient Only) Yes Standard Only meals for the person receiving care are eligible
Meals not at a hospital or similar institution No N/A  
Meals of a companion No N/A  
Meals; attending a medical conference No N/A  
Medic Alert bracelet or necklace Yes Standard  
Medicare Part B premiums No N/A  
Medical conference admission Potentially Standard + letter of medical necessity  
Medical information plan changes Yes Standard  
Medical monitoring and testing devices Yes Standard  
Medical newsletter No N/A  
Medical records charges Yes Standard  
Medical services Yes Standard  
Medicated lip balm Yes Standard Product must be listed as either medicated of having an SPF for sun protection.
Menstrual pain relievers Yes Standard  
Motion sickness pills Yes Standard  
Mouthwash No N/A  
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N
Nail polish No N/A  
Nasal sprays Yes Standard  
Nasal strips Potentially Standard + letter of medical necessity  
Naturopathic healers Yes Standard  
Nebulizer Yes Standard  
Nicotine gum or patches Yes Standard  
Non-prescription drugs used to treat a specific medical condition Yes Standard  
Non-prescription drugs used for general health and /or cosmetic purposes No N/A  
Non-prescription drugs- dual purpose Potentially Standard + letter of medical necessity  
Norplant insertion or removal Yes Standard  
Nursing home expenses No N/A  
Nursing services provided by a nurse or other attendant Yes Standard  
Nursing services for a baby No N/A  
Nutritionist's professional expenses Potentially Standard + letter of medical necessity  
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O
OB/GYN Yes Standard  
Occlusal guards Yes Standard  
Office visits Yes Standard  
One-a-day vitamins No N/A  
Operations Yes Standard Legal operations only
Optometrist Yes Standard  
Organ donors Yes Standard  
Orthodontia Yes Standard  
Orthopedic shoes and inserts Yes Standard The excess cost over ordinary shoes
Osteopath fees Yes Standard  
OTC pregnancy tests/fertility monitors Yes Standard  
Ovulation monitor Yes Standard  
Oxygen Yes Standard  
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P
Pain relievers Yes Standard  
Patterning exercises Yes Standard  
Perfume No N/A  
Permanent waves No N/A  
Personal-only expenses Potentially Standard + letter of medical necessity  
Physical exams Yes Standard Not employment related exams
Physical therapy Yes Standard  
Podiatrist Yes Standard  
Pregnancy Termination Yes Standard Legal terminations only
Pregnancy test kits Yes Standard  
Prenatal vitamins Yes Standard  
Prescription drugs used to treat a specific medical condition Yes Standard  
Prescription drugs used for general health and/or cosmetic purposes No N/A  
Prescription drugs-dual purpose Potentially Standard + letter of medical necessity Not unless the item is used primarily to prevent or alleviate a physical or mental defect or illness
Prescription drugs imported from another country No N/A  
Prescription drug discount programs No N/A  
Prescription eyeglasses Yes Standard  
Propecia Potentially Standard + letter of medical necessity Not unless hair loss is due to a medical condition
Prosthesis Yes Standard  
Psychiatrist Yes Standard  
Psychoanalysis Yes Standard  
Psychologist Yes Standard  
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Q, R
Radial keratotomy Yes Standard  
Reading glasses Yes Standard  
Recliner chairs No N/A  
Retin-A Potentially Standard + letter of medical necessity  
Reversal of tubal ligation or vasectomy Yes Standard  
Rogaine Potentially Standard + letter of medical necessity Not unless hair loss is due to a medical condition
Rubbing alcohol Yes Standard  
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S
Safety glasses No N/A  
Sales tax on qualified medical expenses (e.g. OTC medications) Yes Standard Sales tax will automatically be reimbursed if receipt contains only FSA-eligible expenses. If not, the participant is responsible for calculating the sales tax in order for it to be reimbursed.
Schools and education, residential No N/A  
School and education, special Potentially Standard + letter of medical necessity Only if recommended by a physician
Screening tests Yes Standard  
Shaving cream and lotion No N/A  
Shipping and handling fees on eligible expenses Yes Standard  
Sick-child facility No N/A  
Sinus medications Yes Standard  
Skin moisturizers No N/A  
Sleep deprivation treatment Potentially Standard + letter of medical necessity  
Smoking cessation Yes Standard  
Special foods Potentially Standard + letter of medical necessity  
Spermicidal foam Yes Standard  
Sperm storage fees Potentially Standard + letter of medical necessity Temporary storage only
St. John's Wort Potentially Standard + letter of medical necessity  
Stem cell, harvesting and/or storage Potentially Standard + letter of medical necessity  
Sterilization procedures Yes Standard  
Student health fee No N/A  
Sunglass clips No N/A  
Sunglasses (prescription) Yes Standard  
Sunglasses (non-prescription) No N/A  
Sunburn creams and ointments Yes Standard  
Sunscreen Yes N/A  
Supplies to treat medical condition Yes Standard  
Surrogate expenses No N/A  
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T
Take-home drug test No N/A  
Take-home pregnancy test Yes Yes  
Take-home urinary tract infection test Yes Standard  
Tanning salons and equipment No N/A  
Teeth whitening No N/A  
Telephone for hearing-impaired persons Yes Standard  
Therapy Yes Standard  
Thermometers Yes Standard  
Throat lozenges Yes Standard  
Toiletries No N/A  
Toothache and teething pain relievers Yes Standard  
Toothbrushes No N/A  
Toothpaste No N/A  
Transplants Yes Standard  
Transportation to and from medical conference Potentially Standard + letter of medical necessity See, Medical conference admission, transportation, meals, etc.
Transportation and travel expenses for person receiving dental care Yes Standard 2009 Mileage Rates: Mileage is reimbursable at $.24 per mile for 1/1/09 – 12/31/09. 2008 Mileage Rates: Mileage is reimbursable at $.19 per mile for 1/1/08 – 6/30/08 and reimbursable at $.27 per mile for 7/1/08 – 12/31/08. Note: Participants are required to itemize mileage expenses on the claim form.
Transportation and travel expenses for person receiving medical care Yes Standard 2009 Mileage Rates: Mileage is reimbursable at $.24 per mile for 1/1/09 – 12/31/09. 2008 Mileage Rates: Mileage is reimbursable at $.19 per mile for 1/1/08 – 6/30/08 and reimbursable at $.27 per mile for 7/1/08 – 12/31/08. Note: Participants are required to itemize mileage expenses on the claim form.
Transportation and travel expenses for person receiving vision care Yes Standard 2009 Mileage Rates: Mileage is reimbursable at $.24 per mile for 1/1/09 – 12/31/09. 2008 Mileage Rates: Mileage is reimbursable at $.19 per mile for 1/1/08 – 6/30/08 and reimbursable at $.27 per mile for 7/1/08 – 12/31/08. Note: Participants are required to itemize mileage expenses on the claim form.
Transportation of someone other than the person receiving medical care Potentially Standard Only certain cases are reimbursable. 1) A parent who must travel with a sick child receiving medical care. 2) A nurse or other person who administers medication or injections to a patient. 3) An individual's visits to a mentally-ill dependent, if recommended as part of treatment
Tubal ligation Yes Standard  
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U, V, W, X, Y, Z
Umbilical cord, freezing and storing of Potentially Standard + letter of medical necessity Collection and storage of indefinitely "in case needed" is not eligible for reimbursement
Vaccines Yes Standard  
Varicose veins, treatment of No N/A  
Vasectomy Yes N/A  
Veneer No N/A  
Viagra Yes Standard  
Virtual physical (body scan) Yes Standard  
Vision discount programs No N/A  
Vitamins No N/A  
Walker Yes Standard  
Wart remover treatments No N/A Only to treat a medical condition
Weight-loss programs and/or drugs prescribed to induce weight loss Potentially Standard + letter of medical necessity Only if recommended by a physician
Wigs Potentially Standard + letter of medical necessity Not unless hair loss is due to a medical condition
X-rays Yes Standard  

Orthodontia Expenses

Orthodontia Claims Process


Necessary Documentation for Ortho Claims:
  • A signed and dated claim form
  • A treatment plan that includes the total case fee, initial and monthly fees and the estimated length of treatment (start and end dates)
  • An itemized statement from the servicing provider
  • An EOB from the dental insurance carrier if insurance paid
  • Proof of payment is needed for reimbursement of future services

Example: 24 Month Orthodontia Contract/Cost = $3500.00 including a $500 charge for initial treatment (banding) expenses.
  • Treatment Start Date: August 1, 2007
  • Estimated Completion Date: July 31, 2009
  • Plan Year: January - December

Lump Sum Approach Example: Documentation must include treatment start date, anticipated treatment end date, proof of payment and completed claim form.
2007 - Fees associated with initial treatment expenses (i.e. banding) + fees incurred within the 2007 plan year. 5 months of 2007 (Aug, Sep, Oct, Nov, Dec) x $125 = $625 + $500 for initial treatment. $1,125
2008 - Fees considered incurred within the 2008 plan year ($125 x 12) $1,500
2009 - Fees considered incurred within the 2009 plan year (Treatment completed end of July 2009 - 7 mos. x $125) $875
Total Orthodontia Treatment Expense $3,500

Monthly Approach Example: (A treatment plan or itemized statement and a completed claim form is required with the initial contract/banding claim. For ongoing monthly claims, an itemized statement or payment coupon from the provider and a signed claim form are required)
August 2007 - August Initial Treatment Expense (i.e. banding) $500
August 2007 - August Regular Monthly Expense $125
September 2007 - December 2007 - Participant submits a $125 claim each month (4 mos x $125). Four separate claims. $500
2008 - Regular Monthly Expenses -Participant submits $125 claim each month - (12 mos x $125). Twelve separate claims. $1,500
2009 -Regular Monthly Expenses - Participant submits $125 claim each month - (7 mos x $125) Seven separate claims. Treatment completed end of July 2009 $875
Total Orthodontia Treatment Expenses $3,500




Dependent Care Account Expenses

Dependent Care Claims Process

A signed and dated claim form must accompany each claim.
  • Dependent care expenses must be incurred to allow you and your spouse (if married) to work or look for work. Work includes actively looking for work, but not unpaid volunteer work or volunteer work for a nominal salary. Your spouse is considered to have worked if they are a full-time student for at least five calendar months during the tax year, or if they are physically or mentally incapable of self-care.
  • You may not claim any other tax benefit for the tax-free amounts received by you under the dependent care FSA, although the balance of your eligible employment-related expenses may be eligible for the dependent care credit. Please consult your tax advisor to determine whether the tax credit may be more favorable to you than participating in the dependent care FSA.
  • The child of a divorced or separated employee who has custody of the child is treated as a qualifying individual of the employee. This rule applies even when the non-custodial parent is entitled to the dependency exemption because the custodial parent has released the claim to the exemption. A divorced, non-custodial parent cannot be reimbursed under a DCAP; the divorced, custodial parent can be reimbursed.
  • If both the participant and the provider certifications on the claim form are completed and signed, additional documentation is not required.
  • For claim forms without the provider?s signature, an itemized statement from the dependent care provider is required.
  • Itemized statements should include the date(s) of service, the name and date of birth of the dependent, itemization of charges and the provider?s name, address, and Tax ID/SS number.
  • Expenses paid for dependent care while off work due to illness may be eligible for reimbursement.

Expense Description Eligible? Substantiation Processing Notes
After school care Yes Standard  
Agency fees Potentially Standard Agency fees may be employment-related expenses if the participant is required to pay these expenses to obtain care. However, these fees may not be reimbursed until the care is provided. Forfeited fees are not eligible for reimbursement.
Au Pair Yes Standard Amounts paid for the actual care of the dependent are eligible. See Agency fees
Care for child 13 or older No N/A  
Care for child under age 13 Yes N/A There is a special rule for children of divorced parents. The child is a qualifying individual of the "custodial parent". A divorced, noncustodial parent cannot be reimbursed under a DCAP.
Care for a spouse or other tax dependent who is physically or mentally incapable of self-care (e.g. elderly dependent) Potentially Standard Individual must reside in the participant's home at least eight hours a day. See Nursing home care
Care for person not residing w/ participant No N/A  
Childcare placement agency fees (i.e. finder's fees) No N/A  
Early morning care Yes Standard  
Fieldtrip/activity fees No N/A Ineligible unless incident to and inseparable from the cost of care.
Lessons in lieu of care No N/A  
Materials fees No N/A Ineligible unless incident to and inseparable from the cost of care.
Meals No N/A Ineligible unless incident to and inseparable from the cost of care.
Nanny Yes Standard Only actual care of the dependents is eligible
Nursing home care for a spouse or other tax dependent who is physically or mentally incapable of self-care (e.g. elderly dependent) No N/A  
Overnight camp No N/A  
Payments to a participant's spouse or to a parent of the participant's child who is not the participant's spouse. No N/A  
Registration Fees Potentially Standard Agency fees may be employment-related expenses if the participant is required to pay these expenses to obtain care. However, these fees may not be reimbursed until the care is provided. Forfeited fees are not eligible for reimbursement.
School tuition for kindergarten or above No N/A  
Sick child facility Yes Standard  
Summer day camp Yes Standard  
Transportation expenses to/from care Potentially Standard Only the cost of transportation to or from where care is provided furnished by a dependent care provider may be an employment-related expense (e.g. transportation to and from a day camp or to an after-school program not on school premises).
Tuition for pre k/nursery school Yes Standard  

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Eligible Commuter Benefit Plan Expenses

Transportation/Parking Claims Process

  • A signed and dated claim form must be submitted with each claim along with the provider name, date of service, and amount charged.
  • Expenses must be incurred by an employee to park their car on or near the business premises of their employer or a location from which the employee commutes to work.
  • Expenses must be for transportation provided by:
    • Mass transit facilities, whether or not publicly owned
    • The services of any person in the business of transporting persons for compensation or hire in a "Commuter Highway Vehicle"
    • A "Commuter Highway Vehicle"
    • Carpool (i.e., two or more individuals who commute together in a motor vehicle on regular basis)
  • A receipt is required unless receipts are unobtainable through the normal course of business (e.g., metered parking). If a receipt is unavailable, the participant should check the appropriate box under "Supporting Documentation" on the transit claim form.

*Note: WiredCommute must be used for the transit expenses (substantiation is not required for orders made through WiredCommute).

  Eligible? Substantiation Monthly Reimbursable Amount
Parking Expenses
Parking passes Yes Standard Maximum monthly reimbursable amount for 2009 is $230.00 and $220.00 for 2008.
Park & ride expenses Yes Standard  
Parking meters (at or near work) Yes Standard  
Public Transportation Expenses
Bus Yes Standard  
Car maintenance No N/A  
Ferry Yes Standard  
Gasoline No N/A  
Mileage No N/A  
Subway Yes N/A  
Taxis No N/A  
Tolls No N/A  
Transit passes Yes Standard Maximum monthly reimbursable amount for 2009 is $120.00 and $115.00 for 2008.

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