Do you help with Medicare Advantage appeals

Yes. Medicare Advantage (also called Part C) is one of the plan types Basis Appeals supports out of the box.

What is different about Medicare Advantage

Medicare Advantage plans are private insurers (Aetna, Humana, UnitedHealthcare, Kaiser Permanente, and others) offering Part C plans that replace Original Medicare for the member. The appeal process uses a different rulebook than a commercial group health plan:

• The controlling regulations are at 42 CFR 422.582 (reconsideration) and 42 CFR 422.590 (independent review entity)
• The first-level appeal is called a "reconsideration"
• The window to file is 60 days from the date of the denial notice, not 180 days
• If the plan upholds its denial, the case automatically goes to an Independent Review Entity (IRE); you do not have to request that separately

Basis Appeals writes the reconsideration request with the right citations, the right forum names, and the right window language.

What we cannot help with

• Original Medicare (Part A or Part B). The redetermination process is different. Call 1-800-MEDICARE or use your Medicare Summary Notice.
• Medicare Part D formulary exceptions. These use the coverage-determination and exception process, not the Part C reconsideration process. This is on our roadmap.
• Appeals of the plan's premium or enrollment period issues. Those go to CMS or your State Health Insurance Assistance Program (SHIP).

Expedited requests

Medicare Advantage plans must handle "expedited" reconsiderations within 72 hours when your health could be seriously jeopardized by waiting for a standard timeline (42 CFR 422.584). If your care is urgent, tell the intake form. The letter will include an expedited request that meets the CMS format.

What the plan owes you

Under 42 CFR 422.590, the plan must issue a written reconsideration decision within 30 days for standard pre-service requests, 60 days for standard payment requests, and 72 hours for expedited requests. If they miss the deadline, the case is auto-forwarded to the IRE.

What you should know about the IRE

The Independent Review Entity is a CMS-contracted third-party reviewer. It does not work for the insurer. The IRE reads the plan's file and your appeal and issues its own decision. IRE overturn rates published in CMS enforcement reports historically run in the 30 to 40 percent range depending on the appeal category.

What to gather before the intake form

• The Denial of Medical Coverage or Denial of Payment notice from the plan (this is the "Integrated Denial Notice" form)
• Your Medicare Advantage member ID
• The plan year (last plan year the denial applies to)
• The date of service
• If medical necessity: your prescribing doctor's note explaining why the care was needed

What to do next

Preview a Medicare Advantage draft at /new. Select "Medicare Advantage" as your plan type. The letter will cite Part C, not ERISA.

If your loved one has a Medicare Advantage plan and you are filing on their behalf, you can use the Authorized Representative form (CMS-1696) or the plan's own AOR form. The intake form supports authorized-representative fields.