If you are eligible for reimbursement from:
- The HCFSA, you may be automatically reimbursed for eligible amounts resulting from claims processed as a participant in the ExxonMobil Medical Plan, the ExxonMobil International Medical and Dental Plan, the ExxonMobil Dental Plan and/or the ExxonMobil Vision Plan. For other types of expenses (such as OTC – over the counter- products), you must file a claim form and attach adequate documentation.
- You can enroll in direct deposit throughPayFlex; however, if you submit incorrect direct deposit account information either online or on a paper form, you are responsible for any fees or penalties charged by the financial institution. Direct deposit information needs to be submitted to PayFlex in order to enroll.
- The DCFSA, you must file a claim form and attach adequate documentation.
You may print the ExxonMobil Pre-Tax Spending Plan Health and Dependent Care Flexible Spending Account Claim Form from Employee Connect or ExxonMobil Family websites. You can also file a claim online of by using the PayFlex Mobile app. Step-by-step instructions for filing claims, including where to send the paperwork, are also available on the websites. You may also call Aetna Member Services (1-800-255-2386) for forms or use the forms from the Payflex site. Call Aetna Member Services not PayFlex for questions pertaining to your HCFSA or DCFSA accounts.
The Health Care Flexible Spending Account
PayFlex processes claims for the HCFSA for expenses under the ExxonMobil Medical Plan, the ExxonMobil International Medical and Dental Plan, the ExxonMobil Dental Plan and the ExxonMobil Vision Plan. In most cases, you do not need to file a pre-tax claim form unless you have expenses not processed under these plans. You must opt out of automatic processing for pre-tax reimbursement if you have other medical or dental coverage secondary to your ExxonMobil coverage by contacting Aetna Member Services. If you are a new employee or you did not elect to participate in the HCFSA during the annual enrollment period, you must contact Aetna to enroll in the automatic rollover process. If you do not contact Aetna to enroll, you will be responsible for filing your own claims.
UnitedHealthcare Vision (UHC Vision) processes claims for the ExxonMobil Vision Plan. If you participate in this plan, and UCH Vision processes a claim for the benefit due, you do not need to file a pre-tax claim form for these claims. If you have other vision expenses not processed by UHC Vision under the ExxonMobil Vision Plan, you will have to file a claim form for pre-tax reimbursement withPayFlex.
If you have eligible expenses that are not covered by a medical, dental, pharmacy or vision plan, to be reimbursed you must file a completed Pre-Tax Spending Plan claim form, and:
- An itemized receipt,
- A copy of that plan's explanation of benefits to show that the expense is not covered, or how much the plan paid, and
- Documentation of the claim showing the amount the participant has paid – the documentation being either on the claim or some actual proof of out-of-pocket expense.
Please do not use highlighter on your documentation. Handwritten descriptions of the expenses are not acceptable.
Over-the-counter drug purchases
Over-the-counter (OTC) purchases, both oral and topical, can be reimbursed regardless of whether or not they are prescribed by a physician.
The Dependent Care Flexible Spending Account
You must complete the Dependent Care Flexible Spending Account Claim Form and include supporting documentation. If your caregiver completes and signs the form, you do not need to include an itemized statement. A copy of a canceled check with a fully completed claim form is sufficient if you do not have a bill, voucher or receipt. You will not need a tax identification number (TIN#) displayed in statements for eligible expenses. For questions call 1-800-255-2386 (TTY: 711).
Filing claims for both accounts
- You must file claims for expenses incurred during the plan year (January 1 through December 31) so that they are received by PayFlex no later than April 15 (or if April 15 falls on a non-business day, on the next succeeding business day) following the end of the plan year. This is the ExxonMobil deadline regardless of the IRS deadline. The Plan will not reimburse you for claims received after that date unless you have proof that the claims were to be delivered by the 15th. For example, if a facsimile, the facsimile confirmation to the correct telephone number must be before midnight April 15th. If mailed using a mail or delivery service, the delivery receipt must indicate a guaranteed date by April 15th. Special note: Due to the COVID-19 relief provisions, there is additional time to file claims for reimbursement or appeal a denied claim. For claims incurred in 2020, they can be claimed until the earlier of 60 days after the end of the National Emergency or April 15, 2022.
- If you need to submit a claim, but do not yet have all the required supporting documents, submit the claim so PayFlex receives it before the claim filing deadline. You must submit an itemized bill with your claim submission. You can then submit the supporting documentation later, but in no event can documentation be accepted after the end of the year in which the claim has been submitted. Documentation submitted to support a claim must show a description of the service or provider co-payment received for reimbursement.
- With the exception of the $570 carryover in the Healthcare Flexible spending Account, you forfeit any funds remaining in your accounts for which valid claims have not been received by April 15 following the end of the plan year. Forfeited funds revert to the Plan.
- Payflex allows payments to be sent to providers. You will receive an explanation of payment and a statement showing the status of your account.
- If you file a claim near the April 15 deadline, you may wish to use a mail or delivery service providing a receipt that will help track the claim.
- It is advisable to make photocopies of claims and all supporting materials.
Log into PayFlex to obtain information on current balances.
Benefit claims procedures for HCFSA & DCFSA
Filing a claim
Claim forms may be found at www.exxonmobilfamily.com
Instructions on how to submit your FSA claims for reimbursement electronically:
Alternatively, any member including those under Cigna OAPIN option and Cigna International Medical and Dental Plan can log in via Payflex.com following the below steps: Sign onto your PayFlex account at www.payflex.com.
- After logging in, click on File a claim on the homepage.
- To pay yourself back, select Pay Me.
- Enter your claim information. To add additional claims, select Add Another Claim.
- Once you enter in all of your claims, click Next.
- Confirm all expense details and click Next. To make changes, click Previous.
- Select Fax or Upload.
- To “Fax,” click on Create Coversheet. Print and sign the form. Fax it with your documentation to the number on the coversheet. When you sign the fax coversheet, you certify that your claim is for an eligible expense.
- To “Upload,” use the Browse button. Select your documentation from your computer. To add additional documents, click on Add Additional Document. Note: Each document must be uploaded in PDF format.
- Check the signature box to sign your claim and confirm your submission is for an eligible expense.
- Click Submit.
Direct Deposit Set-up
You also have the option to set up direct deposit to receive your reimbursements more quickly. Set up direct deposit to a U.S. bank account by following these steps:
- Log into the PayFlex.com member portal
- Go to “Account Settings” and click “Bank accounts.”
- Click on “Link Bank Account to my Reimbursement Account.”
- Select the bank account type (checking or savings) and enter your account number and routing number.
- Check the box to authorize PayFlex to link your account and click “Save and Continue.”
Review your bank account information and click “Save and Continue.”
If you have a question or a problem with a HCFSA or DCFSA benefit, contact Aetna Member Services. You must file a claim in writing to Aetna Member Services. Aetna is responsible for determining and informing you of your entitlement to a benefit and any amounts payable to you.
Aetna will review your claim and respond within a designated response time, usually 30 days after receiving your claim. If Aetna needs additional time (an extension) to decide on your claim because of special circumstances, you will be notified within the claim response period. An additional 15 days is all that is allowed. If an extension is necessary, due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice.
If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe
- The specific reason(s) for the denial, and
- The process for requesting an appeal.
Claims Fiduciary and Appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for HCFSA. The Administrator-Benefits is the claims fiduciary for the DCFSA and eligibility. You may contact the claims fiduciary as follows:
|HCFSA Mandatory Appeals:||HCFSA Voluntary and Eligibility Appeals:||DCFSA Mandatory,
Voluntary and Eligibility Appeals:
P. O. Box 981106
El Paso, TX 79998-1106
ExxonMobil Medical Plan
P.O. Box 18025
Norfolk, VA 23501-1867
ExxonMobil Medical Plan
P.O. Box 18025
Norfolk, VA 23501-1867
Filing a mandatory appeal
If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to the appropriate claims fiduciary. If someone is filing a written appeal on your behalf, written authorization from you is required.
For a HCFSA mandatory appeal, please contact Aetna Member Services for information regarding the written authorization and for a DCFSA mandatory and eligibility appeals, please contact the Administrator-Benefits. Your written appeal should include the reasons why you believe the benefit should be paid and information that supports, or is relevant to, your claim (written comments, documents, records, etc.). Your written appeal may also include a request for reasonable access to, and copies of, all documents, records and other information relevant to your claim. You must submit your written appeal within 180 days from the date of the denial notice.
The review will take into account all comments, documents, records and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. The claims fiduciary will respond to the appeal within 60 days.
If the claims fiduciary needs additional time to decide on your claim because of special circumstances, you will be notified within the claim response period. However, an extension may be requested, but the law stipulates that no additional time must be allowed.
If your appeal is denied, you will receive written notice of the decision. The notice will set forth in plain language:
- The specific reason(s) for the denial and the plan provisions upon which the denial is based.
- A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claim.
- A statement of the voluntary appeal procedure and your right to obtain information about such procedure or a description of the voluntary appeal procedure.
- A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA).
Statute of limitations
After you have received the response of the mandatory appeal, you may bring an action under section 502(a) of ERISA. Such action must be filed within one year of the date on which your mandatory appeal was decided.
Filing a voluntary appeal
If your mandatory appeal is denied, you may submit a voluntary appeal to the Administrator-Benefits. New information pertinent to the claim is required for the voluntary appeal to be considered. You must submit your voluntary appeal within 30 days of the denial of your mandatory appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending.
If it is determined that there is new relevant information, a decision will be made within 60 days after the Administrator-Benefits receives your request for a voluntary appeal.