Instructions
Should you encounter any issues during your upload process, you're always welcome to fax your documentation to BASIC FSA (
269.327.0716
) or BASIC HRA (
269.488.6255
)
Please enter your company name below.
What are you submitting?
Claim/Reimbursement Request
Verification (paid for items or services using the BASIC debit card)
Have you already filed this claim online through the participant portal?
( This website is
Not
the participant portal. )
Yes
No
You must include a copy of the online claim confirmation or documentation request with your upload. Failure to provide this required information will result in your submission/documentation
NOT
being processed.
If you have any technical issues please visit
Here
X
Before You Begin...
Do you have all the necessary documentation scanned in an image format ready for upload
(TIFF, TIF, JPG, JPEG, PDF, BMP, PNG, GIF)
? Please make sure you have the necessary documentation for all claims you are entering
Your receipt, service bill, explanation of benefits (EOB), or other documentation must include the following
Date of Service
Description of Service
Service Provider Name
$ Charge Amount
Please note that the best form of documentation is your EOB as it will always contain the above information
Examples
Claim Confirmation With Receipt
Example 2
Example 3
Example 4