GPCCMP FAQ - Practice Management & Clinical Software
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.
Patient Communication & Operational Planning – Templates and tips for engaging patients and planning care delivery efficiently.
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 prepare my practice management software and templates for GPCCMP?
The Bottom Line:
The good news is that your Practice Management System will handle most of the heavy lifting with automatic updates for new MBS items and standard templates. Tools like Cubiko can integrate directly with your PMS to streamline workflows, while you'll need to review any custom templates your practice uses and ensure all unbilled GPMP/TCA items are submitted before July 1, 2025, as they'll no longer be claimable after this date.
The Facts:
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The July 2025 Data Update for Practice Management Systems like Bp Premier will include new MBS items, updates to care plan templates, reminder reasons, and appointment types to support billing and clinical activity under the new framework
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Future PMS program updates will provide additional functionality, such as updated co-claiming logic, updated EPC workflows, enhancements to referral workflows, and MyMedicare Medicare Web Services integration
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New GPCCMP MBS item numbers for GPs and Prescribed Medical Practitioners (face-to-face and telehealth video) will be available in Bp Premier from 1 July 2025
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Internal references in the existing system GPMP and TCA templates will be updated with GPCCMP terminology. New Word Processor templates will also be provided for the GPCCMP Plan and GPCCMP Allied Health Referral Letter
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Custom GPMP and TCA templates will not be automatically updated. Practices using their own templates should manually review and revise wording to match the new format and referral processes
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In many PMS systems new reminder reasons (GPCCMP Plan, GPCCMP Plan Review), reasons for visit (GP CCM Plan, GP CCM Plan Review), and appointment types (GPCCMP Plan, GPCCMP Plan Review) will be introduced
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All unbilled GPMP and TCA MBS items should be submitted before 1 July 2025. After this date, these MBS item numbers will no longer be claimable through Medicare
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Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
Sources: FAQ: GP Chronic Condition Management Plan (GPCCMP), pages 2, 3; Preparing for Chronic Condition Management Changes in Bp Premier, pages 1, 2, 3, 4, 5, 6; Summary of changes to Chronic Disease Management Framework, page 1; 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, pages 1, 2; MBS Online explanatory note AN.0.47
Links and Resources:
Role-Based Implementation Guides:
Billing Support:
How can I use Cubiko to streamline GPCCMP workflows with my PMS?
The Bottom Line:
Tools like Cubiko integrate seamlessly with your PMS to make GPCCMP implementation much smoother. You'll find features like Care Prompts that connect directly to Best Practice appointment books, Item Optimisation metrics to identify eligible patients, and MyMedicare pop-out views that sit alongside your PMS - all designed to reduce admin and improve patient care continuity.
The Facts:
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Cubiko includes a pop-out view that can sit alongside your PMS, showing whether a patient is registered or eligible to register for MyMedicare
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Care Prompts can be sent directly to the Best Practice appointment book to prompt conversations between practitioners and patients about GPCCMP services
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Cubiko's Item Optimisation metrics can generate lists of patients who may be eligible or due for a new GPCCMP, Item 965 or Item 967
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Key Cubiko metrics for GPCCMP management include:
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Possible Service Opportunities Today - identifies patients with appointments today who may be eligible for GPCCMP services
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Cancelled Appointments - tracks patients who have cancelled GPCCMP appointments and may need rebooking
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Appointments to rebook - identifies patients who attended but haven't booked follow-up appointments
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Recalls and Recall appointments to rebook - provides insight into outstanding recall types
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Cubiko dashboards can track CCMP delivery, spot trends and address workflow gaps to support continuous improvement
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Regular audits can identify patients due for GPCCMPs, reviews, immunisations or screenings using integrated data
Sources: Practice Owner & Practice Manager CCMP Workflow, pages 2, 3, 4; Reception CCMP Workflow, pages 1, 2, 3; Nurse CCMP Workflow, pages 1, 2
Links and Resources:
Role-Based Implementation Guides:
Where can I access the new GPCCMP templates?
The Bottom Line:
Many Practice Management System will provide the new GPCCMP templates as part of their standard data updates. You'll find updated internal references in existing templates and brand new Word Processor templates for the GPCCMP Plan and Allied Health Referral Letter, making the transition straightforward for most practices.
The Facts:
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Internal references in the existing system GPMP and TCA templates will be updated with GPCCMP terminology
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New Word Processor templates will be provided for the GPCCMP Plan and GPCCMP Allied Health Referral Letter
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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
Sources: Preparing for Chronic Condition Management Changes in Bp Premier, page 5; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 3.
Links and Resources:
Role-Based Implementation Guides:
Billing Support:
What specific templates and forms need updating for GPCCMP?
The Bottom Line:
You'll need to update any custom GPMP and TCA templates to reflect the new single GPCCMP structure, and transition from structured Medicare forms to standard referral letters for allied health services. The good news is that many Practice Management System will handle standard templates automatically, so you only need to focus on any customised materials your practice uses.
The Facts:
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Custom GPMP and TCA templates will not be automatically updated. If your practice uses custom Word Processor templates for chronic disease management, you will need to manually update them to reflect the new plan structure
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The new referral requirements for allied health services specify that referrals will be in the form of standard referral letters, replacing the previous structured Medicare forms
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Preparing a GPCCMP is defined as preparing a written plan which describes: the patient's chronic condition(s) and associated health care 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 the patient would benefit from multidisciplinary care the services that the medical practitioner will refer the patient to; arrangements to review the plan, including the proposed timeframe for review
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The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs - consultation with at least two collaborating providers is no longer required
Sources: FAQ: GP Chronic Condition Management Plan (GPCCMP), page 2; Preparing for Chronic Condition Management Changes in Bp Premier, pages 1, 5; Summary of changes to Chronic Disease Management Framework, page 1; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 3; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2
Links and Resources:
Role-Based Implementation Guides:
Billing Support:
How do I update appointment types in my practice management software for GPCCMP services?
The Bottom Line:
Your Practice Management System may introduce new appointment types specifically for GPCCMP services as part of its update. These come with default durations, but make sure you adjust them to match your practice's clinical workflows and preferred consultation times. Use tools like Cubiko to help you track which patients need these appointment types proactively.
The Facts:
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New appointment types will be introduced to support patient recall and documentation for GPCCMP related appointments: GPCCMP Plan and GPCCMP Plan Review
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Appointments should be scheduled within the next two weeks following a patient's appointment to support timely and continuous care
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Both opportunistic and proactive engagement approaches can be used - opportunistic through Care Prompts during existing appointments, and proactive through Item Optimisation metrics to identify eligible patients
Sources: Preparing for Chronic Condition Management Changes in Bp Premier, page 5; Reception CCMP Workflow, pages 2, 3
Links and Resources:
Role-Based Implementation Guides:
Billing Support:
What MyMedicare support tools are available to help with GPCCMP implementation?
The Bottom Line:
There are tools available to make MyMedicare registration smooth for your team and patients. You'll find step-by-step workflows, educational materials, and integrated tools that can identify eligible patients and track registration status directly within your practice management workflow.
The Facts:
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Cubiko offers a range of resources to help your team explain the value of MyMedicare in a clear and confident way, including:
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A step-by-step MyMedicare registration workflow
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Printable MyMedicare Educational posters for the waiting room
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Webinar recordings covering key details, benefits and how to engage patients in registration
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Integrated tools can identify patients who are eligible but not yet registered for MyMedicare through:
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MyMedicare eligible patients with an appointment today
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Upcoming telehealth patients who are not MyMedicare registered
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Pop-out views can sit alongside your PMS, showing whether a patient is registered or eligible to register for MyMedicare
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SMS messaging capabilities allow you to download patient lists and send registration information directly
Sources: Practice Owner & Practice Manager CCMP Workflow, pages 2, 3; Reception CCMP Workflow, page 1
Links and Resources:
Role-Based Implementation Guides:
When will automatic co-claiming validation rules be implemented in practice software for GPCCMPs? ?
The Bottom Line:
While new GPCCMP MBS items cannot be co-claimed with general attendance items on the same day, automatic co-claiming validation may not be ready on 1 July 2025.
The Facts:
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Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
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Future versions of Practice Management Systems, such as Bp Premier, will support validation for co-claiming rules
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This functionality is designed to reduce billing errors, support compliance, and streamline claim processing
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Planning and review items for GP chronic condition management plans cannot be co-claimed by the same practitioner on the same day for the same patient as general attendance items (items 3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 123, 124, 151 and 165)
Sources: FAQ: GP Chronic Condition Management Plan (GPCCMP), page 3; Preparing for Chronic Condition Management Changes in Bp Premier, pages 4, 6; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2; MBS Online explanatory note AN.0.47
Links and Resources:
Billing Support:
Can we modify existing GPMP/TCA templates for GPCCMP or do we need completely new documentation?
The Bottom Line:
You can definitely modify your existing custom templates rather than starting from scratch. While your Practice Management System will update its standard templates with new GPCCMP terminology, any custom templates will need manual revision to reflect the new single plan structure and streamlined requirements.
The Facts:
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Custom GPMP and TCA templates will not be automatically updated. If your practice uses custom Word Processor templates for chronic disease management, you will need to manually update them to reflect the new plan structure
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The GPCCMP is intended to set out the patient's treatment and management goals, actions to be taken, and, where multidisciplinary care is required, the services to which the patient will be referred
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The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs - consultation with at least two collaborating providers is no longer required
Sources: FAQ: GP Chronic Condition Management Plan (GPCCMP), page 2; Preparing for Chronic Condition Management Changes in Bp Premier, pages 1, 5; Summary of changes to Chronic Disease Management Framework, page 1; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 3
Links and Resources:
Role-Based Implementation Guides:
Billing Support:
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.