1. ,(
clvrsCENIERS TOR trtEI)ICARt & MEI)ICAIN SERVICES Medicare
April 10,2015
Attention: Sommer Smith
Melissa E. Mendoza. LMSW
Richard Kneip, PI{D, PC
PO Box 210550
Aubunr Hills, MI 48321-0550
Ccrntrol Nurnber: 1 | 56494
Dear Ms, Mendoza:
We are pleased to intbmr you that your initial Medicare enrollment application is approved. Listcd
belorn, are your National Provider Identifler (NPI) and Provider Transaction Access Nurnher (PTAN).
To start billirig. you must use your NPI on all Medicare clairn subrnissions. Because the PTAN is not
considered a Medicare legacy identifier, do not rcport it as an ''other" provider identification number to
the National Plan and Provider Enumcration System (NPPES).
Your PTAN has been activated and will be the required authentication clenrent tbr all inquiries to
custorner service representatives (ClSRs), written inquiry units. and the interactive voice response (tVR)
system. Thc IVR allorvs you to inquire about claims status. bencliciary cligibility, ancl transaction
information. The IVR telephone number is 877 -567 -7201 .Instructions on how to use the IVR can be
ohtained tiom our weh site at: http://wwr.'.wpsnredicare.conr.
To file claims electronically. or if -vou have questions regarding the electronic submission of claims,
please contact our Electronic Data Interchange (EDI) departmerlt at866-234-7331.
Medicare Enrollment [nformation
p,'61,idg1/Supplier nalre: Melissa E. Merrdoza, LMSW
Practicc Locatiori: 89 West South Blvd, Troy, MI48085-l6ll
National Provider Identifier (NPI): 1326141 064
Group or Enrployer National Provider Identifier (NPI): 1679739704
Provider Transaction Access Number {PTAN): N89500014
Group or Ernployer Provider Transaction Access Nurnber (PTAN): 0N89500
Specialty: Clinical Social Worker
You are: Participating
Effcctive Date: I"ehruary 21, 201-5
Please verify thc accuracy of your enrollment inlbrmation.
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2. You are required to submit updates and changes to your cnrolhnent infonnation in accordance rvith
specified tinrefratnes pursuant to 42 CFR$ 121.51 6. Reportable changes include, but are not limited to
changcs in: (l) legal business nanre (LBN)/tax identification nurnber (Tf$, (2) practice location, (3)
ownership, 14) authorized/dclcgated officials. (5) changes in payment information such as clectronic
funds ttansfer infbnnation, and (6) tlnal adverse legal actions, including f-elony convictions, license
suspensions or revocations, alr exclusion or debarment lrom participation in Federal or State health care
plogram, or a Medicare revocation by a difY'erent Medicare contractor.
Providers and suppliers may eiuoll or make changes to their existing emollment in the Medicare
program using the Internet-based Provider Enrollnrent, Chain and Organization System (PECOS). Go to:
www. cms. hhs. govlMedicareProviderSupEnrol l.
Providers and suppliers enrolled in Medicare are required to ensure strict cornpliance with Medicare
regulations. including payment policy and coverage guidelines. CMS conducts numerous fypes of
compliance reviews to ensure providers and suppliers are meeting this obligation. Please visit the
Medicare Lcarning Network at http://www.cms.gov/Outreach-and-Education/Medicare-Leamin-e-
Network-MlNAdlNProducts/index.html for further infonnation about regulations and compliance
reviews, as wcll as Continuing Medical Education (CME) courscs for qualificd providers.
Additional infbrnation about the Medicare program, including billing, f'ee schedules, and Medicare
policies and regulations can be founcl at oul Web site at http://wrvrv.wpsmedicare.com or the Centers fbr
Medicare & Medicaid Services (CMS) Web site at http:/iwww.crns.hhs.gov/homeirnedicare"asp.
If you disagree with the efl-ective date determination in this Ietter, you lxay request a reconsideration
hefbre a contractor hearing otficer. The reconsideration is an independent review and will he conducted
by a person who was not involved in the initial detennination. You must request the reconsideration in
wr:iting to this offi{.:e within 60 calendar days of the postmuk date of this letter. The reconsideration
must state the issues or tindings olfact with rvhich you disagree and the reasorls for disagrecmcnt.
You may submit the additional infonnation with the reconsideration request that you believe may have a
bearing on the decision. The reconsideration request must be signed and dated by the physician, non-
physician practitioner or any responsible authorized or delegatcd official within the entity. Failure to
timely request a reconsideration is deemed a waiver of all rights to further adrninistrative revierv.
The request fbr reconsideration should be sent to:
'Wisconsin
Physicians Service, Medicare Parl B,
Attention: Provider Enrollment Reconsideration Hearing C)ft-tcer, 1717 W. Broadway, Madison. WT
53713,
If you lrave questions regarding the infonnation above, c,all 866-234-7331 between the hours of 7:00
AM and 4:00 PM Central Time.
Sinccrcly,
Kimbcrly Morton
Provider Enrollment Analyst
Wisconsin Physicians Service