HSA/FSA Check List
Before your appointment:
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I contacted my HSA/FSA plan administrator
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I confirmed whether services are eligible
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I confirmed whether an LMN is required
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I requested an LMN from my licensed provider (if needed)
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I know whether my plan requires a receipt or superbill
After payment:
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I requested my receipt/superbill from Pain to Performance Center
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I submitted documentation to my plan administrator
HSA/FSA Reimbursement Guide
How to use HSA/FSA funds for your Pain to Performance Center services
Important Note (Read First) ​Pain to Performance Center is private-pay. We do not bill insurance, Medicare, or Medicaid, and we do not submit claims on your behalf.​ However, some clients may be able to use HSA/FSA funds depending on their plan rules and documentation requirements. Approval is determined by your plan administrator, not by Pain to Performance Center.
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What We Can Provide​​
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A paid invoice/receipt (itemized)
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A superbill for documentation purposes
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Dates of service and service description
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What We Cannot Do​
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We do not bill insurance or submit claims on your behalf.
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We cannot guarantee HSA/FSA reimbursement approval.
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We cannot advise you on tax or legal eligibility—your plan administrator is the final authority.
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Disclaimer HSA/FSA reimbursement is not guaranteed. Eligibility and approval are determined by your plan administrator and may require a Letter of Medical Necessity.
1
Confirm Your Eligibility With Your Plan
Before your appointment, contact your HSA/FSA administrator and ask:
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“Are these services eligible for reimbursement through my HSA/FSA?”
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“Do you require a Letter of Medical Necessity (LMN)?”
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“Do you require a diagnosis code (ICD-10) and/or service codes (CPT)?”
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“Do you require an itemized receipt or a superbill?”
Tip: Every plan is different. Don’t assume coverage based on a friend’s plan.
2
If Required, Get a Letter of Medical Necessity (LMN)
Many FSA plans (and some HSA administrators) require an LMN from a licensed healthcare provider (MD/DO, and sometimes other licensed providers depending on the plan).
If your plan requires an LMN, ask your provider to include:
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Your name and date of birth
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A brief statement of medical need (e.g., “low back pain,” “functional limitations,” etc.)
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Duration of need (example: “valid for 3–12 months,” per plan rules)
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Provider name, credentials, NPI (if applicable), signature/date
3
Pay for Services (Private Pay)
You will pay for services via Zelle or PayPal (credit/debit), per our Payment Policies.
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PayPal includes a 5% processing fee
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The fee is waived with Zelle
4
Request Your Documentation (Receipt / Superbill)
Upon request, we can provide documentation for your records, which may include:
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Itemized paid receipt / invoice, and/or
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Superbill (for reimbursement documentation)
Your HSA/FSA plan administrator will tell you which format they require.
5
Submit to Your HSA/FSA Administrator
Submit the requested documentation through your plan’s portal (or as instructed). Common submission items include:
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Paid receipt/invoice or superbill
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Letter of Medical Necessity (if required)
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Any plan-specific reimbursement form