Employee Assistance Program

Provider Payment

Authorization – The following guidelines apply to all referrals made by MYgroup.

The number of released sessions is found on the Authorization of Service form. This form will be provided by MYG case manager. The password to open the form is “MYgr0up#1” (case sensitive, no quotes, 0 = zero). Authorization for additional sessions must be discussed with MYgroup. If on or before the second visit you assess that the client will need longer-term care than the EAP can offer, the client should be referred out of the EAP, taking into consideration the client’s insurance benefits. If you refer the client to yourself or any professional in your practice, use the Self-Referral Authorization Form (below).

After Assessment, if referral is necessary, mail or fax in the following:

Self-Referral Authorization Form (completed by provider)

Billing Bundle– Mail or fax the following within 90 days of last session date:

Explanation of EAP Services/Notice of Privacy Practices FILLABLE NPP – Password: MYg3@p
Please do not return via digital fax.

Electronic Payment Authorization Form

Provider Electronic Payment Authorization Form

To protect the privacy of the client, please do not email any form with personal health information included (PHI) unless it is encrypted and password protected according to HIPAA compliance standards.

Mail all credentialing information to MYgroup, Attn: Provider Relations, 5925 Carnegie Blvd., Suite 350, Charlotte, NC 28209. Or, fax all information to 704-529-5917. Attn: Provider Relations.

For questions about provider billing, please contact Provider Relations at 866-850-2175 x7945 [email protected] .

* Note: MYgroup does not reimburse for late cancellations or ‘no-shows’ nor can the provider charge for these sessions. However, a ‘no-show’ can be noted as an EAP session as warranted.