<img height="1" width="1" src="https://www.facebook.com/tr?id=302523247453154&amp;ev=PageView &amp;noscript=1">
Skip to content
English
Submit a Support Ticket
  • There are no suggestions because the search field is empty.

GPCCMP FAQ - Patient Communication & Operational Planning

Categories:

Understanding GPCCMP & Key Changes – Overview of the GP Chronic Care Management Program and what’s new under GPCCMP.

Transitioning Existing Patients & Plans – How to move existing care plan patients smoothly into GPCCMP.

Staff Roles & Responsibilities – Clarifies who does what in GPCCMP workflows, from GPs to nurses and admin staff.

Specific Patient Groups & Edge Cases – Advice for managing complex patients and uncommon GPCCMP scenarios.

Practice Management & Clinical Software – Guides for using clinical software and Cubiko tools to support GPCCMP workflows.

MyMedicare Requirements – What practices and patients need to know about MyMedicare registration and eligibility.

MBS Item Numbers & Billing – Understand which MBS items apply, how to claim correctly and avoid common billing errors.

GPCCMP Plan Creation & Reviews – Step-by-step guidance for creating, reviewing and updating GP Chronic Care Management Plans.

Financial Strategy & Practice Efficiency – Practical tips to improve billing accuracy, profitability and workflow efficiency.

Compliance & Quality Assurance – Stay compliant with RACGP, Medicare and MyMedicare requirements when delivering care plans.

Allied Health Referrals Under GPCCMP – How to manage allied health referrals linked to GP Chronic Care Management Plans.

 


How do I identify which patients need transitioning to a GPCCMP?

 

The Bottom Line:

You'll want to focus on patients with existing GPMPs/TCAs who need reviews after July 1, plus identify new chronic condition patients who could benefit from structured care. The good news is that Cubiko's tools can streamline this process, from the "Possible Service Opportunities Today" metric for opportunistic engagement to Care Prompts for Best Practice users, while you maintain flexibility in your clinical decision-making.
 

The Facts:

  • Patients who have an existing GP Management Plan (GPMP) and/or Team Care Arrangement (TCA) in place prior to 1 July 2025 can continue to access services under those plans until 30 June 2027
  • If a patient requires a review of their GPMP and/or TCA after 1 July 2025, they should be transitioned to a new GPCCMP at that time
  • From 1 July 2027, patients will require a GPCCMP to continue accessing MBS-funded allied health and other related services
  • GPCCMPs are for patients with one or more chronic medical conditions that have been (or are likely to be) present for at least 6 months, or is terminal
  • There is no specific list of eligible conditions; it is based on the clinical judgement of the GP or Prescribed Medical Practitioner (PMP)
  • GPCCMPs are not available to patients who are care recipients in a residential aged care facility
  • Two approaches support patient identification: opportunistic engagement (using Care Prompts during appointments) and proactive engagement (using metrics to identify eligible patients for outreach)
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 MBS Items – Transition Arrangements for Existing Patients – 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:

Cubiko Features:
Possible Service Opportunities Today: Identify patients attending today who may be eligible for new GPCCMP, item 965, item 967, or transition from old GPMP/TCA
Item Optimisation metrics: Generate lists of patients who are due or eligible for GPCCMP services
 
Move to CCMP metric: Displays patients who previously may have been eligible for review item 732 and may need transitioning to new GPCCMP
 
Care Prompts (Best Practice users): Sent directly to appointment book to prompt GP conversations with eligible patients
 
MyMedicare eligible patients with appointment today: Broader view of all eligible patients booked today for outreach
Role-Based Implementation Guides:
Billing Support:
Official Information:

What reminder systems should I set up for GPCCMP reviews?

 

The Bottom Line:

You'll need systems to track the 3-month review opportunities and optionally the 12-month GPCCMP preparation cycle. Several software tools and PMS features are available to help. If you use Cubiko, we have built a number of features to help - from monitoring cancelled appointments and overdue reminders to identifying patients who need follow-up rebooking, ensuring patients receive ongoing care while maintaining your practice's financial sustainability with the enhanced fee structure.
 

The Facts:

  • Unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months if clinically relevant. It is not required that a new plan be prepared each year; existing plans can continue to be reviewed
  • GPCCMP reviews can be claimed 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
  • GPCCMP items have equalised fees for planning and reviews ($156.55 for GPs, $125.30 for PMPs), and will be included in the Bulk Billing Practice Incentive Program from 1 November 2025
  • Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers are now formally able to assist with preparation and reviews, with arrangements specified in regulatory frameworks
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – 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:

Cubiko Features:
Cancelled Appointments metric: Track patients who cancel GPCCMP appointments and haven't rebooked
 
Appointments to rebook metric: Identify patients who attended "New CCMP" but haven't booked follow-up "Review of CCMP"
 
Recalls and Recall appointments to rebook: Monitor outstanding recalls by status and age, identify patients who missed recalls
 
Overdue Reminders: Identify reminders flagged by GPs that are still pending action
Patients with upcoming reminders: Track and update reminder systems within your Practice Management System
 
Cubiko Insights: CCM Preparation: Actionable metrics dashboard: Save this dashboard to your 'My Dashboards' to track outstanding 721, 723, and 732 items and help your team action care plans
 
Billing Optimisation and Item Optimisation: Cubiko features that can help identify opportunities for review
 
Role-Based Implementation Guides:
Billing Support:
Official Information:

What's the best way to explain these changes to patients?

 

The Bottom Line:

Focus on how the new framework simplifies their care, enhances continuity, and makes it easier to access necessary services. Frame it as a positive step towards more coordinated and patient-centred chronic condition management, with the added benefit of enhanced team support through formal involvement of practice nurses and Aboriginal and Torres Strait Islander health practitioners.
 

The Facts:

  • The changes are designed to reduce administrative complexity while maintaining quality chronic disease management
  • Patients will be able to access the same range of services currently available through GP management plans and team care arrangements
  • Requirements for allied health providers to provide a written report back to the GP after the provision of certain services are unchanged
  • Patients that had a GP management plan and/or team care arrangement in place prior to 1 July 2025 can continue to access services consistent with those plans for two years
  • Patients will benefit from simplified arrangements and improved continuity of care, as well as better transfer of information between their care team members
  • The requirement to consult with at least two collaborating providers has been removed, streamlining the process
  • From July 1, 2025, referrals to allied health services will be via standard referral letters, offering patients greater choice and flexibility by not needing to specify a particular provider or number of services
  • Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers now have formalised arrangements to assist with the preparation and review of GPCCMPs, enhancing team-based care
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 1; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 1; Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, page 3; MBS Online explanatory note AN.15.3, AN.15.4, AN.15.6
 

Links and Resources:

Communication Support:
Patient Resources:
Official Information:

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

 

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?

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:
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?

 

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
 
 

Disclaimer: This FAQ is for general information only and reflects our understanding of upcoming changes to chronic disease management frameworks at the time of publication. For the most accurate and up-to-date guidance, please refer to official sources such as the Department of Health and Aged Care or Medicare. Cubiko is not responsible for any actions taken based on this information.