Card Transaction Rules

How to Resolve Card Transactions

The Internal Revenue Service (IRS) regulations and other guidance applicable to healthcare benefit cards mandate that each and every electronic payment card payment must be adjudicated and properly substantiated and that only those transactions that fit squarely into very limited “auto adjudication” categories need no additional paper substantiation because they are self-substantiating by their very nature. Below you will find the three categories that allow for “auto adjudication”. If the transaction does not meet the criteria listed below, participants will be required (due to IRS rules) to submit documentation to validate the transaction was eligible under the plan. Click here to view a white paper from Alston & Bird LLP regarding the IRS Debit Card Substantiation Rules.


Inventory Information Approval System

This Inventory Information Approval System (“IIAS”) System was added by Notice 2006-69. Under the IIAS, no additional substantiation is required if the retail merchant compares the item or items to a pre-determined list of covered expenses and restricts use of the card only to those items that fall on that list. Many plan sponsors and administrators are already using health care vendors to verify the transaction at the point of sale by comparing the item(s) to a pre-determined list; Notice 2006-69 simply confirms that this approach is permissible, and opens the door for use of the Card at non-health care merchants. To read more, please click here.


Co-Payment Matching

If the claim for a particular service matches a co-payment imposed for that service under your employers health plan in which the participant or dependent is participating, no substantiation other than the information in the electronic swipe is needed. For example, if your health plan in which the participant or dependent participate imposes a $15 co-pay for all physician office visits and there is a $15 payment to a physician, the plan may assume that such payment is for the co-payment under the health plan and thus no additional substantiation is required. The rule applies equally to pharmacy co-payments imposed by the plan. To read more, please click here.

Recurring previously approved claims

In situations where a claim has been previously approved, a subsequent electronic claim that is the same as the previously approved claim as to a) amount, b) provider, and c) time period (e.g., for prescription drug refills that occur on a regular basis at the same provider for the same amount) will not require additional substantiation. A recurring claim must be accompanied with paper substantiation if the subsequent claim is different as to any of the elements, e.g. provider. Practically speaking, very few claims will satisfy this auto-adjudication parameter. To read more, please click here.

Helpful Debit Card Video’s

In these quick video’s we talk about the IRS rules that oversee the usage of the healthcare debit card and why participants are required at times to submit supporting documentation.

Important things to remember!
  • OCA may request receipts to verify expense eligibility, so keep all receipts.
  • The card is only valid at authorized merchants.
  • Card can be used up to the amount available in your account.
  • Transactions over the available amount will be denied.
  • OTC items require a prescription presented at point of sale to be considered eligible.
  • 24/7 access to account information at