7. 200000001275 - Schedule M - Sample Admin Fee Claims Invoice.xlsx

This is a Sample Administrative Fee Claims Invoice template for the 2020 Montgomery County Schools Consortium (MCSC) Flexible Spending Account (FSA) Request for Proposal, specifically designed to document monthly FSA claims and administrative costs. The invoice template is structured to capture claims data across multiple FSA plan types, including Health Care (HC) FSA plans offered as both General Purpose and Limited Purpose options, Dependent Care (DC) FSA plans, carryover amounts for HC FSA plans, and run-out period charges for DC FSA plans. The template provides line items for recording total invoiced claims by month and FSA plan category, with separate sections for calculating monthly administrative fees based on participant counts for each FSA plan type combination.

The pricing structure in the invoice template allows for itemized monthly administrative fee calculations per plan type, with the template calculating total monthly costs by multiplying participant counts by the applicable per-participant administrative fee rate. All sample values are currently displayed as zero dollars, indicating this is a blank template format for vendors to demonstrate their invoicing methodology and fee structures. The template consolidates FSA claims expenses and administrative fees into a single comprehensive monthly invoice, enabling clear tracking of claims processing costs and participant-based administrative charges across the various FSA plan options offered under the MCSC consortium agreement.