Aetna federal policy identification number

• Retain copies for your files. Claim information cannot be returned.
  
• Do not highlight or otherwise mark the form or enclosed documentation. Highlighting and other marks make scanned and faxed documents difficult to read.

FSA Identification Number - As a participant with the FSA, you have been assigned a unique participant number. Your FSA ID Number is a 9 digit number preceded with a "W". If you do not know your W#, you can locate it from any one of the following sources:

• Explanation of Payment (EOP) - Paper EOPs always display your W#.
  
• Activity Statement - As an Aetna FSA participant you may receive an activity statement at least once a year; refer to this statement for your W#.
  
• Aetna Medical ID Card - If you have Aetna medical coverage, this W# displayed on your ID card is also used for your FSA.
  
• Member Services - Call FSA Member Services to inquire about your W#. NOTE: If you prefer, you can use your Social Security Number in this field. Employee's Address - Report an address change to your employer. To avoid misdirected claim payments, your employer must notify Aetna of your new address.
  

FSA Control Number - Your employer has been assigned a unique FSA plan number. If this form does not have that number pre-printed, you can locate this number from any one of the sources (with the exception of the Aetna Medical ID card) listed above in Section 1.

List and separate expenses by individual family members. Attach the appropriate documentation for each claim.
Note: A canceled check is not adequate documentation.

If you have insurance that covers part of this expense or your insurance does not cover this expense at all.
Submit the Explanation of Benefits (EOB) with your completed claim form. You do not need to submit any other documentation with the EOB. For a prescription drug claim, refer to the instructions to the right.

NOTE: Any third party documentation that indicates insurance has not yet paid (e.g., pre-treatment estimate) will be returned to you. You will need to resubmit the claim once you have received a final EOB; the EOB must show that the insurance has paid its portion of the claim.

For an Rx claim or if you do not have insurance:

Submit the itemized receipt or statement from the doctor/dentist/pharmacist/health care professional. This itemized receipt or statement must include:

NOTE: Receipt from doctor/dentist/pharmacist must clearly document patient's financial responsibility.

For Orthodontia claims, please follow these guidelines.

• When submitting your first orthodontia claim, you must submit the orthodontia contract from the orthodontist along with a signed Flexible Spending Account Health Care Reimbursement form. This contract must indicate initial fee charged, estimated insurance payment, initial start date, duration of treatment, and proof partial or full down payment.
  
• For each monthly request for reimbursement, you must submit a completed and signed claim form with an itemized bill/statement or receipt from the orthodontist. This statement must show the monthly charge consistent with the original orthodontic contract.
  
• Future dates of services cannot be submitted. IRS guidelines require services to be incurred before you can be reimbursed. A reimbursement request for a service that will occur in a subsequent plan year will be returned to you for resubmission in that plan year.
  

When an expense is covered under more than one health plan, both Explanation of Benefits must be submitted in order to process the reimbursement.

You must sign and date this form to avoid claim payment delays.