Flexible Spending Account Letter of Medical Necessity

Under Internal Revenue Service (IRS) rules, some health care services and products are only eligible for reimbursement from your Flexible Spending Account (FSA) when your doctor or other licensed health care provider certifies that they are medically necessary. Your provider must indicate your (or your spouse’s or dependent’s) specific diagnosis, the specific treatment needed, how this treatment will alleviate your medical condition and length of treatment time.

Johnson County Government has developed this letter to assist you and your health care provider in providing the information needed to process your claim. Your provider can also submit a statement on his or her letterhead, as long as the letter includes all of the information on this form.

Please review IRS code 502 on www.irs.gov website or the Johnson County Government Eligible and Ineligible expense list on the OFM-Benefits website for clarification when this letter is a necessity. Please contact OFM-Benefits at (913) 715-0700 if you have questions.

Please submit this completed form or a letter from your provider with your claim submission. This letter will be valid for expenses incurred for one year or as specified by the practitioner from the date of the letter. At the end of one year, a new letter will be required.

[Date]
[Employee Name]	[SSN/EID#]
[Patient Name]
[Diagnosis]	[CPT Code]
Dear Johnson County Government:
Please describe what the recommended treatment is, how that treatment will alleviate the diagnosis or symptoms and the duration of the treatment required.
Sincerely, [Provider Signature]
[Provider Name] [Provider License # & State] Provider Telephone #]

Note: Johnson County Government’s role is to ensure that the proper documentation is submitted for reimbursement under the 125 Cafeteria Plan. The Johnson County Benefit’s staff will review this letter of medical necessity for completeness.