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HSA/FSA Check List

Before your appointment:

 

  1. I contacted my HSA/FSA plan administrator

  2. I confirmed whether services are eligible

  3. I confirmed whether an LMN is required

  4. I requested an LMN from my licensed provider (if needed)

  5. I know whether my plan requires a receipt or superbill

 

After payment:
 

  1. I requested my receipt/superbill from Pain to Performance Center

  2. 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) â€‹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​​

  • A paid invoice/receipt (itemized)

  • A superbill for documentation purposes

  • Dates of service and service description

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What We Cannot Do​

  • We do not bill insurance or submit claims on your behalf.

  • We cannot guarantee HSA/FSA reimbursement approval.

  • 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:

 

  • “Are these services eligible for reimbursement through my HSA/FSA?”

  • “Do you require a Letter of Medical Necessity (LMN)?”

  • “Do you require a diagnosis code (ICD-10) and/or service codes (CPT)?”

  • “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:

 

  • Your name and date of birth

  • A brief statement of medical need (e.g., “low back pain,” “functional limitations,” etc.)

  • Duration of need (example: “valid for 3–12 months,” per plan rules)

  • 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.

 

  • PayPal includes a 5% processing fee

  • The fee is waived with Zelle

4

Request Your Documentation (Receipt / Superbill)

Upon request, we can provide documentation for your records, which may include:

 

  • Itemized paid receipt / invoice, and/or

  • 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:

 

  • Paid receipt/invoice or superbill

  • Letter of Medical Necessity (if required)

  • Any plan-specific reimbursement form

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