Houston ISD FSA · administered by Zynera
✕ What NOT to send
FSA Document Clinic — why claims get denied
The other half of the library, in the same categories as the good samples. Each exhibit is a realistic supporting document that fails substantiation — with red pins on the exact problems, why it fails, and the fix. Every one is a fictitious, watermarked sample.
14 insufficient
2 partially eligible
2 needs a companion doc
18 exhibits
How to read an exhibit: the document is on the left with numbered red pins on each problem; the panel on the right explains why it fails and ends with a green ✓ what to send instead. Open any exhibit for the full-size version.
Medical
Doctor visits, labs, specialists
✕ Insufficient
Credit-card receipt
A credit-card slip with no description of service
No description of the service or item. A charge slip proves money moved, not what it was for — so there's no way to tell if the expense is §213(d) eligible.
✕ Insufficient
Balance-forward statement
A 'balance forward' statement with no service detail
'Previous balance / payment on account' tells you money was owed and paid — but not for what.
✕ Insufficient
Appointment confirmation
An appointment confirmation, mistaken for a receipt
It's an appointment reminder/confirmation. It proves you have an appointment — not that a service was performed and paid for.
✕ Insufficient
Statement + receipt stapled over it
A card receipt stapled over the statement, hiding the details
The credit-card receipt is stapled on top of the statement, covering the service descriptions and charges underneath — a reviewer can't see what the care was or what it cost.
Dental
Cleanings, restorative, orthodontia
✕ Insufficient
Pre-treatment estimate
A treatment estimate for care that hasn't happened yet
It's labeled an ESTIMATE / treatment plan. FSA reimburses expenses that have been incurred — the care actually provided — not care that's merely planned.
✕ Needs a companion doc
Orthodontia auto-pay receipt
A monthly braces payment with no treatment contract
Orthodontia is substantiated by the signed treatment contract + payment schedule — one contract covers the whole course of care. This monthly receipt has no contract behind it.
✕ Insufficient
Insurer pre-determination
A benefits 'pre-determination' mistaken for an EOB
A pre-determination ('pre-D') is the insurer quoting what they'd cover if you get the work — it is not an EOB.
✕ Insufficient
Statement + receipt stapled over it
A card receipt stapled over a dental statement
The credit-card receipt is stapled on top of the statement, covering the ADA/CDT descriptions and charges underneath — a reviewer can't see which procedures were done or what they cost.
Vision
Exams, glasses, contacts
✕ Partially eligible
Optical statement
Eyewear statement bundled with a product warranty
The 2-Year Protection Plan / warranty ($89) is not FSA-eligible. A product warranty or service contract isn't medical care under IRS §213(d) — eyeglasses are eligible, but a plan to replace them if they break is not.
✕ Insufficient
Online order — shipping email
A shipping-confirmation email instead of an itemized receipt
A shipping confirmation shows an order shipped and a total — not what the items were.
✕ Insufficient
Non-prescription eyewear
Fashion sunglasses with no corrective prescription
Prescription eyeglasses and prescription sunglasses are eligible — but these are marked Sugar Land (non-prescription).
✕ Insufficient
Statement + receipt stapled over it
A card receipt stapled over a vision statement
The credit-card receipt is stapled on top of the statement, covering the exam, frames, and lens lines and their charges underneath — a reviewer can't tell it's prescription eyewear or what it cost.
Pharmacy
Prescriptions, OTC & supplements
✕ Partially eligible
Store register receipt
A store receipt mixing eligible and everyday items
Only the allergy medicine ($12.49) is FSA-eligible. OTC drugs like loratadine qualify (no Rx needed since 2020) — that one line is good.
✕ Insufficient
Front-register receipt
A front-register 'RX' receipt with no prescription detail
A front-register receipt shows you paid for 'a prescription' — but not which one. No drug name or Rx number.
✕ Needs a companion doc
Supplements — no LMN
Vitamins and supplements without a Letter of Medical Necessity
The receipt itself is good — it names each item, the date, and the amount.
Dependent Care
Daycare, camps, in-home — DCFSA
✕ Insufficient
Daycare receipt
Dependent-care tuition paid in advance
The tuition is prepaid for September, before that care happens. DCFSA reimburses only care that has already been provided — never prepaid tuition or deposits.
✕ Insufficient
Overnight camp
A sleepaway (overnight) camp — day camp only
Only DAY camp qualifies for DCFSA. This is a residential / overnight (sleepaway) camp.
✕ Insufficient
School tuition
Kindergarten tuition — education, not dependent care
DCFSA covers care so you can work — not education. Kindergarten and above is schooling.
Looking for the good examples instead? → FSA Sample Documents (what good ones look like)