A claim denial means your submitted claim has been rejected and the expense will not be covered or reimbursed. When a claim is denied, you'll receive a notification explaining the specific reason why it wasn't approved.
Common reasons for claim denial
Insurance companies and benefits administrators may deny claims for various reasons:
- Service not covered: The treatment or service isn't included in your plan
- Pre-existing condition exclusion: Some plans exclude conditions that existed before coverage started
- Missing documentation: Receipts or medical records are unclear or incomplete
- Waiting period: Service was received before your coverage started
- Annual limit exceeded: You've used up your annual benefit limit
- Not medically necessary: The treatment isn't considered necessary for your condition
- Duplicate claim: You've already submitted this claim before
- Out of network: Provider isn't in your network (if your plan has network restrictions)
- Excluded services: The service is specifically excluded from your plan (like cosmetic procedures)
Claim denials in Soda
Soda makes it clear why a claim was denied and what you can do about it:
How you'll be notified:
- Push notification in the Doctor Anywhere app
- Status update in the "Claims" section of the app (under Coverage)
- Clear reason for the denial
Common denial reasons in Soda:
- Annual limit exceeded: You've reached your annual benefit limit for the policy year
- Service not covered: The service isn't included in your specific plan
- Unclear documentation: Receipt photo is blurry or information is missing
- Duplicate claim: This claim was already submitted and processed
- Ineligible expense: The expense doesn't meet your plan's coverage rules (especially for flex benefits)
- Date outside coverage period: Service was received before your coverage started or after it ended