Loudoun County Public Schools Flexible Benefits Account

CompuSys/Erisa Group Inc.

Founded in 1968 Licensed Third Party

Administrator Administer Flexible

Benefits Compensation

Introduction

Continuity Great Service

– Over 99% claims turn-around within 5 days with 100% financial accuracy

New Options– FSA debit card– Direct Deposit of reimbursement accounts– Weekly check runs– Dedicated internal website for 24/7 online access to

account balance, claim history, claim submission, and additional FSA Information

Benefits Debit Card

The Flexible Benefits Debit Card is a special purpose MasterCard® that gives you an automatic way to pay for qualified healthcare expenses from your Flexible Benefit Plan. It works like a MasterCard® Card, with the value of your yearly target amount stored on it.

What happens when I receive my Benefits Card?

You will receive one card, though you may request another.

Your card will be activated with the first swipe of the card.

There will be no fees associated with the card.

How Do I use my card?

It works like a MasterCard® Card, with the value of your yearly target amount stored on it.

It's from that total target dollar amount that eligible expenses will be deducted as you use your card. When you have eligible expenses at a business that accepts MasterCard®, simply use your Card.

The amount of your eligible purchases will be deducted automatically from your account and the pre-tax dollars will be electronically transferred to the provider/merchant for immediate payment.

Where can I use my Benefits Card?

For prescriptions at a chain pharmacy or grocery store.

At a hospital or doctor’s office (After you use your card you will receive a documentation request for anything other than a co-pay).

At a dentist office (After you use your card you will receive a documentation request).

At your vision care provider (After you use your card you will receive a documentation request).

Documentation Requests

In order to verify that you have used your card for items that are eligible under your flex plan you will receive a letter from us asking for supporting documentation.

After you receive a request for documentation please mail, fax or email back the requested information along with the letter.

The following slides outline acceptable forms of documentation.

Medical/Dental

For doctor or dentist visits, an EOB is the preferred form of documentation. If you do not have a copy of the EOB, please obtain an itemized bill from the provider that clearly shows the date of service, patient, provider name, insurance payments/write offs, and the service provided. For co-pays the bill must indicate the date of service, patient, provider name and co-pay amount.

Vision Care

For Vision care, please provide an itemized bill that has the patient name, description of the service provided, the cost of the service provided, the date of service and the provider name.

Prescriptions

For prescriptions, please provide a copy of the prescription tag that indicates the patient name, when the prescription was filled, the name of the prescription, the pharmacy name and the cost of the prescription.

Over the Counter Items

For non-medicinal over the counter items, please provide a cash register receipt that shows the date of purchase, name of item purchased and the store name.

You will not be able to use your Debit Card to purchase medicinal over the counter items.

What happens if I am unable to submit the requested documentation?

You can pay back your account by sending a check to CompuSys/Erisa.

You can submit offsetting documentation. You will have 45 days to submit the

requested documentation, pay back your account, or submit offsetting documentation.

Are there places the Prepaid Benefits Card won’t be accepted?

Your card will not be accepted at locations that do not offer eligible goods and services, such as hardware stores, restaurants, bookstores, gas stations and home improvement stores.

If asked, should I select “Debit” or “Credit”

The Card is actually a prepaid Card. But, since there is no "prepaid" selection available, you’ll select "Credit." You do not need a PIN and you cannot get cash with the Prepaid Benefits Card.

Account Balance

How do I know how much is in my account? – You will receive quarterly statements from

CompuSys/Erisa.– You can log on to your account at lcpsflex.com. – You can call CompuSys/Erisa to obtain your current

balance.

What if I go over my account balance? – If you try to make a purchase that is over your account

balance the transaction will be denied for insufficient funds. Your purchase cannot exceed the amount of money currently in your Flexible Benefit Plan.

I received an old medical bill can I use my card to pay for it?

You can only use your card for expenses in the current plan year. If you receive a bill in 2011 for an expense that incurred in 2010 you can’t use your card to pay the bill.

If you are new to the plan and use your card to pay for a bill before you enrolled in the plan, you can’t use your card to pay the bill.

If you do use your card to pay for a bill for a previous plan year, or prior to your enrollment in the plan, you will be require to pay back your account.

What can I do on lcpsflex.com?

The lcpsflex.com website allows you to :– Under the heading Forms, print out claim forms and

print out direct deposit authorization forms.– Under the heading Eligible Expenses, you can verify

whether something will be reimbursable under your Flex Benefit Plan.

– Have basic questions answered about your Flexible Benefit Plan under the Q&A.

– Have basic questions answered about your debit card, under the heading Flexible Benefits Card.

– File a claim online.

Claims

How to file a Claim

To obtain a claim form:– Log on to

lcpsflex.com and look under the heading Forms

– Call 1-800-933-7472 to request claim forms

White: Administrative Office Canary: Employee Copy

CompuSys/Erisa Group Inc CLAIM FORM FOR LOUDOUN COUNTY PUBLIC SCHOOLS

FLEXIBLE BENEFITS PLAN

PLEASE PRINT OR TYPE. SEE REVERSE SIDE FOR INSTRUCTIONS AND IMPORTANT INFORMATION

Administrative Office: CompuSys/Erisa Group Inc • 12325 Hymeadow Drive, Bldg. 4-100 • Austin, TX 78750 • (800) 933-7472 • Fax (512) 250-9487 • E-mail, flex@cserisa.com

EMPLOYEE INFORMATION NAME PERSONAL IDENTIFICATION (PID)

MAIL ADDRESS: if your address has recently changed, you must update your address through your employer CITY STATE ZIP CODE

EMAIL ADDRESS: HOME: AREA CODE AND PHONE NUMBER WORK: AREA CODE AND PHONE NUMBER

HEALTHCARE REIMBURSEMENT

To ensure prompt processing, attach copies of the Explanation of Benefits statement from your insurance carrier and any additional supporting documentation as described on the reverse of this form for each of the reimbursement requests listed below.

DATE OF SERVICE SERVICE PROVIDER AMOUNT OF REIMBURSEMENT

1

2

3

4

5

6

7

REIMBURSE FROM PLAN YEAR_________(specify year) TOTAL AMOUNT TO REIMBURSE: $

DEPENDENT CARE REIMBURSEMENT

Please provide all of the requested information

DEPENDENT’S NAME & RELATIONSHIP TO YOU DOB DATES OF SERVICE AMOUNT PAID

1

2

3

4

TOTAL AMOUNT TO REIMBURSE: $

DEPENDENT CARE PROVIDER INFORMATION (If your Dependent Care Provider does not provide you with an itemized receipt the PROVIDER must fill in the information below as a receipt of services)

For instructions, see “Dependent Care Expenses” in the Supporting Documentation section on the back of this form. NAME OF DEPENDENT CARE PROVIDER SOCIAL SECURITY/TAX-ID NUMBER

DATE OF SERVICE: FROM / / TO / /

AMOUNT PAID NATURE OF SERVICE: (i.e. day care, other school care, etc)

SIGNATURE OF DEPENDENT CARE PROVIDER DATE

EMPLOYEE CERTIFICATION AND SIGNATURE

I certify the charges attached or listed above are eligible under the Internal Revenue Code, the charges have been incurred, and that I have not been reimbursed by, nor are the charges reimbursable by any other source. I also certify that I will not claim these charges as a credit on my personal income tax return. I also certify that the total dependent care expenses (if any) for which I am requesting reimbursement for this plan year do not exceed the lesser of my or my spouse’s earned income for the year. I further certify that the expenses I am submitting for payment are eligible expenses, as explained in my open enrollment material and in I.R.S. publications 502 and 503. EMPLOYEE’S SIGNATURE DATE

When filing your claim, please make sure that:

You have included your PID issued to you by Loudoun County Public Schools.

You have made copies of all of your receipts for your own personal records.

You have verified that each line item on the claim form corresponds with a receipt/ Explanation of Benefits/itemized bill that you are submitting.

Each bill states the patient name, the date of the visit, the provider of the service, cost of the service, and insurance payment.

The bill shows actual insurance payments, not pre-estimates.

You include a letter of medical necessity from a doctor for medicinal over the counter items.

Each dependent care bill states the dates of service, service provider, service provider tax id, and amount charged.

If you do not have an itemized bill from your Dependent Care Provider, have your Dependent Care Provider complete the Dependent Care portion of the claim form.

You include the date of birth of your child when filing for dependent care.

You, the employee, have signed and dated the claim form.

Claim filing options

You may mail a claim to: CompuSys/Erisa at : 12325 Hymeadow Dr., Bldg 4-100

Austin Texas 78750 You may fax a claim to CompuSys/Erisa at 1-512-

250-9487. You may send an email with your claim as an

attachment to CompuSys/Erisa at flex@cserisa.com. You may file a claim online at lcpsflex.com

To File an Online Claim

• Log on to the lcpsflex.com website.

• Click on My Account, and then enter your Employee PID issued by Loudoun County, and the PIN issued to you by CompuSys/Erisa

You will come to the Balances page, click on Personal Information and enter in all of your dependents.

Look at the top and click on Claims, then look to the top left and click the File a Claim Button.

The top section of the page is for healthcare reimbursement requests. Fill in the dates of service, patient name, service provider, and amount of reimbursement for each itemized bill that you are attaching.

The bottom section of the page is for Dependent Care claims. Make sure to fill in all of the fields for each dependent.

After you’ve read the Employee Certification message click the I Agree Button.

Use the Browse button to upload your itemized bills. Make sure the attachment you upload is no bigger then 10 Megabytes.

Once you’ve uploaded all of your attachments, click the Submit button.

The Website

What else can I do on the website?

In addition to filing a claim, you can view your balance.

Look at all of your payroll deductions.

View your claims history.

Look at your payment history.

Questions

If you have any additional questions, please contact CompuSys/Erisa at

1-800-933-7472. You may also email us at

flex@cserisa.com.