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Click here: HRA Claim form

For Medical Expenses, you must provide a copy of the insurance carrier’s Explanation of Benefits (EOB) as supporting documentation for your claim form. If this is not provided, the claim cannot be processed. Should there be any discrepancy between the information on the EOB and the information provided on the claim form for that expense, the EOB will rule. (For example, if the EOB indicates that the approved amount of the service was $300.00,  but that only $250.00 was the patient’s responsibility, and the claim form asks for a $300.00 reimbursement, the claim amount will be changed to $250.00 by our personnel when the claim is entered because the EOB specifies that amount   as the actual patient  responsibility.)

Click here: FSA Claim form

For Medical Expenses, you must provide a provider receipt or insurance carrier explanation of benefits (EOB) that contains ALL of the information listed under “For Medical Expenses” above. Cancelled checks, non-detailed credit card receipts, or generic cash receipts do not provide all the information necessary to substantiate claims and cannot be accepted. Statements with “Previous Balance”, “Balance Forward”, or “Paid on Account” do not contain all of the necessary information and cannot be accepted.

For Dependent Day Care Expenses, you must provide either a receipt that contains ALL of the information listed above under “For Dependent Day Care Expenses” or a signature of the Care Provider on the completed claim form. Expenses submitted for Dependent Care Reimbursement must allow the participant to be gainfully employed (or looking for work). Overnight camps, extracurricular activity fees, care for children over the age of 12, and private school fees (for grades Kindergarten and up) are not eligible expenses for Dependent Care reimbursement.

Click here: DCA Claim Form

For Dependent Day Care Expenses, you must provide either a receipt that contains ALL of the information listed above under “For Dependent Day Care Expenses” or a signature of the Care Provider on the completed claim form. Expenses submitted for Dependent Care Reimbursement must allow the participant to be gainfully employed (or looking for work). Overnight camps, extracurricular activity fees, care for children over the age of 12, and private school fees (for grades Kindergarten and up) are not eligible expenses for Dependent Care reimbursement.

Click here: Commuter Claim Form

Due to recent IRS changes, employees can only be reimbursed for transit expenses via a “voucher” or terminal restricted debit card.

Each employee enrolled in the transit benefit will receive O.C.A.’s terminal restricted mySource debit card.The mySource card will have your monthly election available on the card to pay for your monthly transit expense. Please note that funds can only be reimbursed once the employee has contributed monies into their parking and/or transit benefit. So if the employee has not made any payroll contributions, no funds will be available on the mySource debit card.

If enrolled in parking, employees may be reimbursed via paper check or direct deposit. This does not apply towards transit expenses.

All mySource transactions must be substantiated in order to confirm that all items paid for with pre-tax dollars are eligible under the IRS guidelines. 

Depending on what your mySource card purchase was used for, may or may not necessitate the need for you to submit a claim form and documentation to support your purchase. This is an IRS requirement. For audit purposes, you should always retain your receipts!

Examples of automated substantiation (no follow-up “should” be required):

    • Purchases that are made at retail stores (i.e. CVS, Target, Wal-Mart) with an federally approved point of sale approval system (IIAS) in place that restricts purchases with your pre-tax dollars to FSA eligible expenses.
    • Purchases that match a known co-pay amount for health, vision or dental plan you have elected through your employer. If your insurance plan has co-insurance or deductibles, you can use the card to pay for these expenses, but you will ALWAYS be required to provide documentation to substantiate your purchase.Below is an example of a transaction that would require you to submit a claim form and documentation.

Email: Claims@oca125.com I Fax Number: 609-514-2778