GPCCMP Frequently Asked Questions - part 2

Chronic Condition Management Hub

Patient Resources:

Official Information:

Chronic Condition Management Resource Pack

What patient communication templates should I use to explain the changes?

Patient Communication & Operational Planning

The Bottom Line:

While no specific patient communication templates are universally provided in the sources, you'll need to adapt or create your own materials to effectively explain the GPCCMP changes. Focus on updating your existing communication channels with the new terminology and processes.

The Facts:

The new framework introduces the GP Chronic Condition Management Plan (GPCCMP), which replaces the existing GP Management Plan (GPMP) and Team Care Arrangement (TCA)
New MBS item numbers apply for plan preparation and review (965/967 for GPs, 392/393 for PMPs, with corresponding telehealth items)
Referrals to allied health providers will now be made via a referral letter rather than a structured form
Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers now have formal arrangements to assist with the preparation and review of GPCCMPs
The MBS factsheets don't provide specific information on patient communication templates

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 1; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.15.3, AN.15.4, AN.15.6

Links and Resources:

Communication Resources:

Cubiko Blog: "Everything practices need to know about the new Chronic Condition Management Announcements"

Role-Based Implementation Guides:

Practice Management Resources:

Best Practice Software: New Word Processor templates for the GPCCMP Plan and GPCCMP Allied Health Referral Letter as part of their July 2025 Data Update

Custom templates: Will require manual revision to reflect the new plan structure, including removing references to separate team care arrangements

Billing Support:

Official Information:

What should I do with any unbilled GPMP or TCA items now that the deadline has passed?

Patient Communication & Operational Planning

The Bottom Line:

The deadline for billing old GPMP and TCA items was 1 July 2025. Our current understanding is that services provided before 1 July 2025 using the old item numbers can still be billed if they were performed before that date, but you'll need to transition to the new GPCCMP items ($156.55 for GPs, $125.30 for PMPs) for any new plans or reviews. This needs to be confirmed.

The Facts:

From 1 July 2025 the following MBS items ceased: GP management plans – 229, 721, 92024, 92055; Team care arrangements – 230, 723, 92025, 92056; Reviews – 233, 732, 92028, 92059
From 1 July 2025: any new plans put in place will need to meet the requirements of a GPCCMP
All unbilled GPMP and TCA items must have been submitted before 1 July 2025. After this date, these item numbers are no longer claimable through Medicare
New GPCCMP items (965/967 for GPs, 392/393 for PMPs) are now available with enhanced fee structure and formal arrangements for practice nurse, Aboriginal and Torres Strait Islander Health Practitioner and Aboriginal Health Worker assistance

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 2; Summary of changes to Chronic Disease Management (CDM) Framework, page 1; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.15.3, AN.15.4, AN.15.6

Links and Resources:

Billing Support:

MBS Online Transition Arrangements

Services Australia Provider Enquiry Line: 13 21 50

Transition Guidance:

Role-Based Implementation Guides:

Official Information:

How should I update my allied health provider contact list for the new referral system?

Patient Communication & Operational Planning

The Bottom Line:

The referral format has changed from forms to letters, but your existing provider relationships remain the same. You'll want to let your allied health contacts know about the new letter format and ensure they understand the updated reporting requirements.

The Facts:

From 1 July 2025, referral forms will no longer be used for referrals to allied health services
Referral letters will be used, consistent with the referral process for medical specialists
There is no requirement for allied health providers to confirm acceptance of the referral or otherwise provide input into the preparation of the GPCCMP
However, the requirements for allied health providers to provide a written report back to the GP after the provision of certain services (e.g. the first service under a referral) are unchanged
Unless otherwise specified by the referring medical practitioner, referrals to allied health services for patients with a chronic condition will be valid for 18 months
Referrals do not need to specify the name of the allied health provider to provide the services or specify the number of services to be provided

Sources: Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 2; MBS Online explanatory note AN.15.6; MBS Online explanatory note AN.15.3, AN.15.4

Links and Resources:

Referral Guidelines:

MBS Online Allied Health Referrals

Allied Health Information:

MBS Online Allied Health Providers

Practice Resources:

Chronic Condition Management Hub

Role-Based Implementation Guides:

Aboriginal and Torres Strait Islander Health Practitioner CCMP Workflow

Official Information:

When is a GPCCMP required for domiciliary medication management reviews?

Specific Patient Groups & Edge Cases

The Bottom Line:

A GPCCMP will become a mandatory requirement for patients to access Domiciliary Medication Management Reviews (DMMR) from July 1st, 2027. This provides a clear transition period to ensure all patients needing these reviews are integrated into the new GPCCMP framework, with fees of $180.65 for GPs and $125.30 for PMPs.

The Facts:

From 1 July 2027, a GP Chronic Condition Management Plan (GPCCMP) will be required to access domiciliary medication management reviews (MBS items 245 and 900)
This requirement is in addition to the existing criteria for MBS items 245 and 900
Patients with an existing GPMP and/or TCA prior to 1 July 2025 can continue to access DMMRs through the MBS until 30 June 2027
After 1 July 2027, only patients with a GPCCMP will be eligible to access DMMRs through the MBS
Item 900 (GP participation in DMMR) has a fee of $180.65 with 100% benefit, and item 245 (PMP participation) has corresponding fees
These services can be claimed once every 12 months for any particular patient, except if there has been a significant change in the patient's condition or medication regimen requiring a new DMMR

Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, page 1; MBS Online explanatory note AN.0.52; MBS Online explanatory note AN.15.3

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

How have medication review arrangements changed now that GPCCMP is in place?

Specific Patient Groups & Edge Cases

The Bottom Line:

While the core Domiciliary Medication Management Review (DMMR) items themselves haven't changed, the main shift is that from July 1, 2027, a patient will need a GPCCMP to access these services. This solidifies the GPCCMP as the central framework for chronic condition management, including structured medication reviews with substantial fees justifying the comprehensive approach.

The Facts:

From 1 July 2027, a GP Chronic Condition Management Plan (GPCCMP) will be required to access domiciliary medication management reviews (MBS items 245 and 900)
This requirement is in addition to the existing criteria for MBS items 245 and 900
Patients with a GPMP and/or TCA in place prior to 1 July 2025 can continue to access these services under those plans until 30 June 2027
The DMMR process remains the same: GP assessment, referral to community pharmacy or accredited pharmacist, discussion of results, development of written medication management plan, and provision to patient's chosen pharmacy
Services are claimable once every 12 months per patient, with exceptions for significant changes in condition or medication regimen

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

Are there any other MBS services that now require a GPCCMP — or are expected to soon?

Specific Patient Groups & Edge Cases

The Bottom Line:

Beyond the main chronic disease management changes, the GPCCMP requirements are quite focused. From July 2027, you'll need a GPCCMP for ongoing allied health services and domiciliary medication management reviews, but that's essentially it.

The Facts:

From 1 July 2027, a GP chronic condition management plan will be required for ongoing access to allied health services
From 1 July 2027, a GP chronic condition management plan will be required to access domiciliary medication management reviews (items 245 and 900)
These changes do not affect multidisciplinary care plan items (231, 232, 729, 731, 92026, 92027, 92057, 92058)
Individual allied health services (up to 5 per calendar year, 10 for Aboriginal and Torres Strait Islander patients) require a GPCCMP that has been prepared or reviewed in the previous 18 months
Group allied health services for type 2 diabetes management continue to be available with a GPCCMP
Practice nurse and Aboriginal and Torres Strait Islander health practitioner services (items 10997, 93201, 93203) require a GPCCMP and are limited to 5 services per calendar year
Aboriginal and Torres Strait Islander health services (items 10950, 81300, 93000, 93013, 93048, 93061) are available to patients with a GPCCMP, with fees of $72.65 and 85% benefit ($61.80) for most services

Sources: RACGP Summary of changes to Chronic Disease Management (CDM) Framework, page 2; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; MBS Online explanatory note AN.15.3; MBS Online explanatory note AN.15.5, AN.15.6

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

What happens to the 8 group sessions for Type 2 Diabetes under the new system?

Specific Patient Groups & Edge Cases

The Bottom Line:

Patients with a GPCCMP can continue to access group services for type 2 diabetes management. The 8 sessions per calendar year remain available across dietetics, diabetes education, and exercise physiology services, with assessment fees of $93.25 and individual group session fees of $23.20, ensuring these vital services continue uninterrupted under the new framework.

The Facts:

Patients can access up to 8 group services for the management of type 2 diabetes per calendar year
This access is provided following an assessment of their suitability for group dietetics, diabetes education, or exercise physiology services
These services are available where they are consistent with the patient's GPCCMP
The item descriptors for these services have been updated due to the removal of GPMPs and TCAs, and the commencement of GPCCMPs
Assessment for group services (items 81100, 81110, 81120) has a fee of $93.25 with 85% benefit ($79.30), payable once per calendar year
Individual group sessions (items 81105, 81115, 81125) have a fee of $23.20 with 85% benefit ($19.75), to a maximum of 8 sessions per calendar year
Services are provided to groups of 2-12 patients and require at least 60 minutes duration
Group services are available for patients with type 2 diabetes who have either a GPCCMP or are residents of an aged care facility with a multidisciplinary care plan

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 2; MBS Online explanatory note AN.15.3; MBS Online explanatory note AN.15.5, AN.15.6, MN.9.1, MN.9.2

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

How do GPCCMP changes affect specialised clinics (skin cancer, aesthetics, etc.)?

Specific Patient Groups & Edge Cases

The Bottom Line:

The GPCCMP framework is specifically designed for the structured management of chronic medical conditions that are long-term or terminal. Since specialised clinics like skin cancer or aesthetics generally fall outside the scope of chronic condition management as defined by the MBS, these clinics are unlikely to be directly affected by the GPCCMP requirements.

The Facts:

A GPCCMP is available to patients with at least one medical condition that has been (or is likely to be) present for at least 6 months or is terminal
It is up to the GP or PMP's clinical judgment to determine whether an individual patient with a chronic condition would benefit from a GPCCMP
The GPCCMP framework specifically targets chronic disease management and associated allied health services
There is no specific list of eligible conditions; clinical judgment determines appropriateness based on the chronic nature and management benefit

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 3; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.15.3, AN.15.4

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

How do we handle NDIS or DVA patients under the new GPCCMP structure?

Specific Patient Groups & Edge Cases

The Bottom Line:

The new GPCCMP framework streamlines chronic disease management by replacing the old GPMP and TCA items. The good news is that these changes do not affect other MBS-supported allied health services such as Mental Health Treatment Plans or DVA services, which continue under their existing frameworks and item numbers, maintaining separate pathways for these specific patient groups.

The Facts:

The GPCCMP requirements do not apply to other MBS-supported allied health services such as Mental Health Treatment Plans, Eating Disorder Plans, Palliative Care, and DVA services
These other plans remain under their existing frameworks and item numbers
Specifically, the new referral requirements do not apply to Better Access psychological therapy services, focussed psychological strategies (allied mental health) services, eating disorder allied health services, or diagnostic audiology services
NDIS patients may still benefit from GPCCMPs for chronic condition management where clinically appropriate, but their NDIS-funded services continue under existing arrangements
The GPCCMP framework operates parallel to, rather than replacing, other specific health service frameworks
Patients with mental health conditions or eating disorders may be eligible for treatment through the Better Access mental health items or eating disorder items, which have specific eligibility criteria detailed in item-specific explanatory notes

Sources: Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 3; MBS Online explanatory note AN.15.3; MBS Online explanatory note AN.0.56, AN.36.2, AN.15.6

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

Do the changes affect multidisciplinary care plan items or other multidisciplinary services available to patients?

Specific Patient Groups & Edge Cases

The Bottom Line:

These changes do not affect existing multidisciplinary care plan items (like those for residential aged care facilities), which continue under their current framework with fees of $65.70 for PMPs and $82.10 for GPs.

The Facts:

The changes to the chronic disease management framework do not affect multidisciplinary care plan items (231, 232, 729, 731, 92026, 92027, 92057, 92058)
GPCCMPs are not available to patients in residential aged care facilities; allied health services for these patients are available through a multidisciplinary care plan
The requirement to consult with at least two collaborating providers, as described under the current Team Care Arrangements, will be removed
There is no requirement for allied health providers to confirm acceptance of the referral or provide input into the preparation of the GPCCMP
Multidisciplinary care plans allow the general practitioner/prescribed medical practitioner to contribute to a plan which may be coordinated by another provider
Items 232, 731, 92027 and 92058 are available for patients living in a residential aged care facility; items 231, 729, 92026 and 92057 are available for patients not in residential aged care

Sources: RACGP Summary of changes to Chronic Disease Management (CDM) Framework, page 2; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, pages 1, 3; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 3, 4; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; MBS Online explanatory note AN.15.3; MBS Online explanatory note AN.15.7, AN.15.8

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

Can a GPCCMP be created for emergency or urgent chronic condition management needs?

Specific Patient Groups & Edge Cases

The Bottom Line:

While the GPCCMP is designed for a structured, ongoing approach to chronic conditions, the good news is that a plan can be prepared or reviewed earlier than the usual timeframe if exceptional circumstances apply. This built-in flexibility allows you to adapt to urgent situations where a new plan or review is clinically relevant outside the typical 3-month or 12-month intervals, with full fee entitlements maintained.

The Facts:

Unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months if it is clinically relevant
Reviews can be conducted once every 3 months, if clinically relevant, unless exceptional circumstances apply
Plans may be prepared or reviewed earlier if exceptional circumstances apply
The MBS fee structure remains the same regardless of timing: $156.55 for GPs and $125.30 for PMPs for both preparation and review
Clinical relevance and exceptional circumstances are determined by the GP or prescribed medical practitioner's professional judgment

Sources: RACGP Summary of changes to Chronic Disease Management (CDM) Framework, page 2; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 2, 4; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.15.3, AN.15.4

Links and Resources:

Role-Based Implementation Guides:

Practice Resources:

Official Information:

What are the compliance requirements and documentation standards for GPCCMP?

Compliance & Quality Assurance

The Bottom Line:

The good news is that GPCCMP documentation requirements are clearly defined and much more streamlined than the old system. The requirements include specific plan components, proper consent procedures, and record-keeping standards.

The Facts:

Preparing a GPCCMP is defined as preparing a written plan that describes:
The patient's chronic condition(s) and associated healthcare needs
Health and lifestyle goals developed by the patient and medical practitioner using a shared decision-making approach
Actions to be taken by the patient
Treatment and services the patient is likely to need
If multidisciplinary care is beneficial, the services to which the patient will be referred (including their purposes)
Arrangements to review the plan, including the proposed timeframe for review
The process of developing and finalising a GPCCMP must include:
Recording the patient's consent and agreement to the plan preparation
Offering a copy of the plan to the patient and their carer (if any, and if appropriate and agreed)
Adding a copy of the plan to the patient's medical records
If referring to a multidisciplinary team, the GP or PMP must:
Obtain the patient's consent to sharing relevant information, including relevant parts of the plan, with the multidisciplinary team
If the patient consents, provide relevant parts of the plan to the members of the multidisciplinary team, in addition to the referral
Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers may assist with the development or review of a GPCCMP, though the GP or PMP retains responsibility for the service and must see the patient as part of the service
GPs and PMPs are encouraged to upload the GPCCMP to My Health Record if the patient consents
Providers must keep adequate and contemporaneous records, and where an MBS item specifies the creation of a document, that document must be retained for 2 years

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 3-4; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.0.47, AN.15.3

Links and Resources:

Implementation Support:

Aboriginal and Torres Strait Islander Health Practitioner CCMP Workflow

Official Documentation:

Services Australia Provider Enquiry Line: 13 21 50

Will Medicare review our GPCCMPs, and how often will these reviews occur for quality and compliance purposes?

Compliance & Quality Assurance

The Bottom Line:

Yes, Medicare services including GPCCMPs are subject to ongoing compliance checks, and providers may be asked to submit evidence of services billed. Additionally, the GPCCMP framework itself will be subject to post-implementation review around two years after introduction. Providers are responsible for ensuring services meet all legislative requirements and keeping adequate records.

The Facts:

Changes to MBS items are subject to post-implementation review, which typically occurs around 2 years after implementation of the change
Providers are responsible for ensuring Medicare services claimed using their provider number meet all legislative requirements
All Medicare claiming is subject to compliance checks, and providers may be required to submit evidence about the services they bill
Providers should ensure they keep adequate and contemporaneous records for all GPCCMP services
Providers seeking advice on interpretation of MBS items, explanatory notes and associated legislation can use the Department of Health, Disability and Ageing's email advice service by emailing askMBS@health.gov.au
Practices can subscribe to future MBS updates by visiting 'Subscribe to the MBS' on the MBS Online website, and to 'News for Health Professionals' on the Services Australia website to receive regular news highlights

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 6; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 4; MBS Online explanatory note AN.0.47

Links and Resources:

Compliance Information:

Medicare Compliance Information: Available on Department of Health, Disability and Ageing website

Quality Assurance:

Official Resources:

Services Australia Provider Enquiry Line: 13 21 50

Services Australia Health Professionals

Has Medicare released guidance on fixing minor billing errors with GPCCMP items?

Compliance & Quality Assurance

The Bottom Line:

There is no specific guidance on fixing minor billing errors for GPCCMP. For current billing issues, the recommended approach is direct contact with Services Australia.

The Facts:

Providers are responsible for ensuring Medicare services claimed using their provider number meet all legislative requirements
All Medicare claiming is subject to compliance checks, and providers may be required to submit evidence about the services they bill
Future Practice Management System updates will introduce co-claiming validation to assist with billing accuracy when claiming the new GPCCMP items, which is designed to reduce billing errors and support compliance

Sources: Preparing for Chronic Condition Management Changes in Bp Premier, pages 5, 7; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 6; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.0.47

Links and Resources:

Billing Support:

Services Australia Provider Enquiry Line: 13 21 50

Practice Management:

Services Australia Health Professionals

How long does Medicare take to correct billing mistakes under GPCCMP?

Compliance & Quality Assurance

The Bottom Line:

The MBS factsheets don't cover specific timeframes for billing corrections - that's operational detail that Services Australia handles directly. For timing queries, contacting their Provider Enquiry Line is the recommended approach.

The Facts:

The MBS factsheets don't provide specific information on this topic. Services Australia handles operational billing corrections and can provide current timeframes for specific situations.

Links and Resources:

Billing Support:

Services Australia Provider Enquiry Line: 13 21 50

Practice Management:

How do we keep care quality high and track which patients need GPCCMP attention to prevent them falling through the cracks?

Compliance & Quality Assurance

The Bottom Line:

The new GPCCMP framework emphasises regular reviews and streamlined processes to support high-quality care. Tools like Cubiko's can help identify eligible patients and forecast billings.

The Facts:

A key objective of the changes to the arrangements for chronic condition management is to encourage regular reviews of GPCCMPs
Patients will need to have their GPCCMP prepared or reviewed in the previous 18 months to continue to access allied health services
Unless exceptional circumstances apply, items for preparing a GPCCMP can be claimed every 12 months if clinically relevant; GPCCMP reviews are available every 3 months if clinically relevant
Reviewing a GPCCMP means the GP or PMP must discuss and document patient progress in relation to goals, and whether any updates should be made, taking into account information from multidisciplinary teams
The process of reviewing a GPCCMP must include recording patient consent, offering a copy of the updated plan to the patient, and adding it to the patient's medical records
Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers may assist with the review process, working alongside practitioners to prepare and document GPCCMP appointments
You'll find that Cubiko's Quality Improvement Measures and PDSA cycle make it easy to track progress.
Regular auditing of patient records is recommended to identify those due for GPCCMPs, reviews, investigations, immunisations or screenings to support proactive care delivery and prevent patients from being missed

Links and Resources:

Quality Management Tools:

Patient Tracking & Audit Tools:

Cubiko Quality Improvement Measures & PDSA Cycle: Track 10997 billings and set targets for continuous improvement

Planning Resources:

What are the specific penalties for non-compliance with GPCCMP requirements?

Compliance & Quality Assurance

The Bottom Line:

The MBS factsheets consistently emphasise that compliance checks are standard practice and providers are responsible for ensuring services meet legislative requirements. While they don't specify particular penalties, they do note that providers may need to submit evidence about billed services. Providers must keep adequate records, with documents requiring retention for 2 years where MBS items specify document creation.

The Facts:

Providers are responsible for ensuring Medicare services claimed using their provider number meet all legislative requirements
All Medicare claiming is subject to compliance checks, and providers may be required to submit evidence about the services they bill
Providers must ensure they keep adequate and contemporaneous records, with documents requiring retention for 2 years where MBS items specify document creation
More information about the Department of Health, Disability and Ageing's compliance program can be found on its website at Medicare compliance

Links and Resources:

Compliance Information:

Medicare Compliance Information: Available on Department of Health, Disability and Ageing website

Services Australia Provider Enquiry Line: 13 21 50

Risk Management:

Official Information:

Department MBS Email Advice Service: askMBS@health.gov.au

Subscribe to MBS Updates: Available on MBS Online website

Services Australia News for Health Professionals: Subscribe on Services Australia website

Services Australia Provider Enquiry Line: 13 21 50

What's the best way to set fees for GPCCMP – should we bulk bill or charge privately?

Financial Strategy & Practice Efficiency

The Bottom Line:

It is up to your practice and your practitioners. GPCCMP items are eligible for bulk billing incentives when you bulk bill eligible patients, and they'll be included in the Bulk Billing Practice Incentive Program from 1 November 2025. Here's what this means for your practice finances: the impact will depend on your billing approach for each patient - the new fees represent a change from previous arrangements where GPMP preparation was $164.35, TCA preparation was $130.25, and reviews were $82.10.

The Facts:

GPCCMP items may be claimed with single bulk billing incentives when eligible patients are bulk billed and will be included in the Bulk Billing Practice Incentive Program from 1 November 2025
The MBS fees for planning and review items are equalised, with both the 965 and 967 items providing a fee of $156.55 for GPs and $125.30 for PMPs
Previously, the rebate for preparation of a GPMP was $164.35, preparation of TCAs was $130.25 and a review was $82.10
The impact of the changes on annual funding for chronic disease management will depend on the billing approach for each patient
To encourage reviews and ongoing care, the MBS fees for planning and review items will be equalised at $156.55 for GPs and $125.30 for prescribed medical practitioners

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; RACGP Summary of changes to Chronic Disease Management (CDM) Framework, page 1

Links and Resources:

Financial Planning:

Billing Support:

Visual Item Transition Guide: Shows exact transitions from old items (721/723→965, 732→967, etc.)

Official Information:

Services Australia Provider Enquiry Line: 13 21 50

Should I change consultation appointment lengths for GPCCMP creation and reviews for optimal efficiency?

Financial Strategy & Practice Efficiency

The Bottom Line:

The MBS factsheets don't provide specific guidance on optimal appointment lengths for GPCCMP services. The practical reality is you have complete flexibility to adjust appointment lengths to match your practice's workflows and clinical preferences but also sustainable business reality.

The Facts:

The MBS factsheets don't provide specific guidance on optimal appointment lengths for GPCCMP services.

Note: Workflow documents suggest considering the comprehensive time requirements for GPCCMP services when scheduling appointments.

Links and Resources:

Workflow Planning:

Efficiency Analysis:

How can I optimise the financial benefits of the new GPCCMP system?

Financial Strategy & Practice Efficiency

The Bottom Line:

The key to the new program is the equalised fees for both plan preparation and reviews, plus the range of services that can be accessed under each GPCCMP. With reviews available every 3 months if clinically relevant and consistent fees of $156.55 for GPs, you'll find this creates much more predictable revenue streams and opportunity for patient engagement.

The Facts:

The MBS fee to prepare a GPCCMP is $156.55 for GPs and $125.30 for PMPs
Unless exceptional circumstances apply, items for preparing a GPCCMP can be claimed every 12 months if clinically relevant; GPCCMP reviews are available every 3 months if clinically relevant
GPCCMP items may be claimed with single bulk billing incentives when eligible patients are bulk billed and will be included in the Bulk Billing Practice Incentive Program from 1 November 2025
To encourage reviews and ongoing care, the MBS fees for planning and review items are equalised at $156.55 for GPs and $125.30 for prescribed medical practitioners
An existing GPCCMP can be reviewed and amended on an ongoing basis, and it is not required that a new plan be prepared each year
Patients can access up to 5 individual allied health services per calendar year (10 services for patients of Aboriginal or Torres Strait Islander descent) and up to 5 services provided by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner (item 10997 at $14.00 fee)
For patients with type 2 diabetes, an assessment of their suitability for group services and, if suitable, up to 8 group services for diabetes management per calendar year

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2, 3, 4; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; MBS Online explanatory note MN.12.4

Links and Resources:

Financial Modelling:

Strategic Planning:

Billing Support:

How often should I schedule GPCCMP reviews to get the best balance of care and financial sustainability?

Financial Strategy & Practice Efficiency

The Bottom Line:

We are currently producing some resources to assist you with this.

The Facts:

Unless exceptional circumstances apply, GPCCMP reviews are available every 3 months if clinically relevant
Plans may be prepared or reviewed earlier if exceptional circumstances apply
While GPCCMPs do not expire, patients must have had a GPCCMP prepared or reviewed in the previous 18 months to continue to access allied health and other services under the plan
To encourage reviews and ongoing care, the MBS fees for planning and review items are equalised at $156.55 for GPs and $125.30 for prescribed medical practitioners
An existing GPCCMP can be reviewed and amended on an ongoing basis, and it is not required that a new plan be prepared each year

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 4; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2

Links and Resources:

Financial Planning:

Clinical Planning:

Billing Reference:

How can I keep workflows smooth, reduce admin, and manage the ongoing workload with GPCCMP in place?

Financial Strategy & Practice Efficiency

The Bottom Line:

Here's what's helpful to know: the new GPCCMP framework is designed to simplify chronic condition management by removing collaboration requirements and multiple plan complexity. The practical reality is that this streamlined approach should reduce administrative burden compared to the previous GPMP/TCA system.

The Facts:

The changes aim to simplify, streamline, and modernise the arrangements for health professionals
The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs. Consultation with at least two collaborating providers is no longer required
There is no requirement for allied health providers to confirm acceptance of the referral or otherwise provide input into the preparation of the GPCCMP
GPs and PMPs can refer patients with a GPCCMP directly to relevant services
Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled; patients that are not registered may access the services through their usual GP
You'll find that Cubiko's suite of metrics makes it easy to support workflow management: Recalls, Overdue Reminders, Appointments with no rebookings, and Cancelled Appointments help identify workflow gaps and support continuous improvement
From 1 July 2027, a GPCCMP will be required to access domiciliary medication management reviews (items 245 and 900), creating additional future opportunities for integrated care planning

Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 5; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, pages 2, 3; Practice Owner and Practice Manager CCMP Workflow

Links and Resources:

Workflow Streamlining:

Efficiency Tools:

Administrative Support: