FSA Guidelines for Orthodontia Reimbursements

The only orthodontia payments that are eligible for reimbursement through a Flexible Spending Account are the scheduled payments shown on a contract or payment schedule. Extra payments and late fees are not eligible.

There are two basic formats to Orthodontia reimbursements. The following information should help you to decide which format you prefer.

Manual Reimbursements
If you require reimbursement on a specific date of the month, you should submit a copy of a payment schedule or an orthodontia contract with your first request form. In subsequent months you may request reimbursement for your orthodontia payment by submitting a completed request form each month as your payments come due. If you submit your payment schedule or orthodontia contract the first month, you will not need to submit any other documentation with subsequent request forms. PacificSource is not able to reimburse payment amounts that differ from amounts shown as due on a payment schedule or orthodontia contract without further documentation.
Automatic Reimbursements
You may opt to receive automatic reimbursements by submitting a request form once each FSA plan year and requesting automatic reimbursement on the form. At the beginning of the plan year, send to PacificSource a copy of the orthodontia contract that states your monthly payment. On the 10th of each month (or the following working day) we will reimburse that month’s payment as stated on the orthodontia contract. You should expect to receive the automatic reimbursement between the 15th and 20th of each month. This method requires only one request for reimbursement form each year.

Remember, if you need to receive reimbursement by a specific date, you must submit a request form each month to ensure your receipt date. This request should be received by PacificSource at least one week prior to the date you need to receive reimbursement.

If your orthodontia contract extends over two or more years, your first reimbursement payment in the new plan year will be made only after your first payroll deduction is received by PacificSource.

If you have questions regarding orthodontia reimbursement, please contact PacificSource. To have your reimbursement directly deposited in your bank account, please complete an EFT/Direct Deposit Authorization Form and send it to PacificSource