GPCCMP Frequently Asked Questions - part 1

What is the GPCCMP and how is it different from current GPMPs and TCAs?

• From 1 July 2025, GPMPs and TCAs are replaced with a single GP chronic condition management plan (GPCCMP)
• The GPCCMP introduces a single, streamlined approach, moving your team from managing two separate planning processes to one
• A GPCCMP outlines the patient's chronic conditions, care goals, treatment actions, referrals (if needed), and a review schedule
• Under the new framework, the requirement for GPs or Prescribed Medical Practitioners (PMPs) to consult with at least two collaborating providers as part of a Team Care Arrangement (TCA) has been removed
• GPs and PMPs can now refer patients with a GPCCMP directly to relevant services without requiring allied health providers to confirm acceptance of the referral
• Referrals to allied health providers will be made via a standard referral letter, no longer requiring a structured Medicare form
• New MBS item numbers apply for GPCCMP preparation and review: 965 (GP face-to-face), 92029 (GP telehealth video), 392 (PMP face-to-face), and 92060 (PMP telehealth video) for plan development; and 967 (GP face-to-face), 92030 (GP telehealth video), 393 (PMP face-to-face), and 92061 (PMP telehealth video) for plan reviews, replacing all existing GPMP and TCA items
• The ability for practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers to assist in the preparation of a GPCCMP has been specified in the regulatory arrangements for the new items
• Patients registered with MyMedicare will be required to access GPCCMP services through their registered practice, enhancing continuity of care, while patients not registered with MyMedicare can access these services at any practice but should use their usual GP

• From 1 July 2025, the existing MBS items for GP Management Plans (GPMPs) (229, 721, 92024, 92055), Team Care Arrangements (TCAs) (230, 723, 92025, 92056), and their reviews (233, 732, 92028, 92059) ceased and are replaced by a new streamlined GPCCMP
• Eight new MBS item numbers became billable for GPCCMP: 965 (GP face-to-face), 92029 (GP telehealth video), 392 (PMP face-to-face), and 92060 (PMP telehealth video) for plan development; and 967 (GP face-to-face), 92030 (GP telehealth video), 393 (PMP face-to-face), and 92061 (PMP telehealth video) for plan reviews
• The MBS fees for planning and review items are equalised to $156.55 for GPs and $125.30 for Prescribed Medical Practitioners (PMPs)
• The requirement to consult with at least two collaborating providers for a Team Care Arrangement has been removed
• Allied health referrals now use a standard referral letter, consistent with referrals to medical specialists, no longer requiring a structured Medicare form
• The ability for practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers to assist in the preparation of a GPCCMP has been specified in the regulatory arrangements
• Patients registered with MyMedicare are required to access GPCCMP services through their registered practice. Patients not registered with MyMedicare can continue to access these services through their usual GP
• Existing GPMPs and TCAs, along with associated referrals, remain valid until 30 June 2027, allowing a transition period
• From 1 July 2027, a GPCCMP will be required for ongoing access to allied health services and Domiciliary Medication Management Reviews (items 245 and 900)
• 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 changes are a result of a review by the MBS Review Taskforce, informed by the General Practice and Primary Care Clinical Committee
• The General Practice and Primary Care Clinical Committee was established in 2016 to provide broad clinician and consumer expertise
• The MBS Review included a public consultation process from December 2018 to March 2019, with feedback received from a broad range of stakeholders
• Following the MBS Review, ongoing consultation occurred through an Implementation Liaison Group including the Australian Medical Association, Royal Australian College of General Practitioners, Rural Doctors Association, Allied Health Professionals Australia, the Australian Primary Health Care Nurses Association, the National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners, and other professional associations
• The framework aims to:
• Make care planning easier for practices and patients
• Encourage regular, structured reviews
• Reduce paperwork and streamline referral and claiming processes
• Strengthen continuity of care through the MyMedicare patient registration system
• Formalise arrangements for support provided by practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers
• One of the objectives is to provide patients with greater choice and flexibility in accessing allied health services

• The new framework introduces a single GP Chronic Condition Management Plan (GPCCMP) that replaces the existing GP Management Plan (GPMP) and Team Care Arrangement (TCA), meaning your team will move from managing two separate planning processes to a single, streamlined approach
• The requirement to consult with at least two collaborating providers as part of a Team Care Arrangement has been removed. GPs and Prescribed Medical Practitioners (PMPs) can now refer patients directly to relevant services
• Referrals to allied health providers will be issued via a standard referral letter, no longer requiring a structured Medicare form, which simplifies the referral process
• The ability for practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP has been specified in the regulatory arrangements for the new items
• The changes aim to simplify, streamline, and modernise the arrangements for health professionals
• Use of referral letters will support the provision of relevant clinical information to allied health professionals
• MyMedicare registration requirements support continuity of care through strengthened usual medical practitioner requirements

• A GPCCMP is available to patients with at least one chronic medical condition that has been (or is likely to be) present for at least 6 months, or is terminal
• There is no specific list of eligible conditions. It is up to the GP or Prescribed Medical Practitioner (PMP) to determine, based on their clinical judgment, whether an individual patient with a chronic condition would benefit from a GPCCMP
• Patients registered with MyMedicare are required to access GPCCMP services through their registered practice, while patients not registered with MyMedicare can access these services at any practice but should use their usual GP. These requirements apply to both face-to-face and telehealth items
• The eligibility criteria are the same as under the previous GPMP/TCA system, except that GPCCMPs are not available to patients who are care recipients in a residential aged care facility (though allied health services remain available to RACF patients through multidisciplinary care plans)

• GPCCMPs are not available to patients who are care recipients in a residential aged care facility
• Allied health services are available to patients in residential aged care facilities through a multidisciplinary care plan

• A GPCCMP does not expire under the new framework. Once prepared, it can be used indefinitely with regular reviews
• To maintain access to MBS-funded Allied Health Services, a GPCCMP must have been prepared or reviewed in the previous 18 months
• GPCCMP preparation can be claimed once every 12 months, if clinically appropriate. 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 appropriate. Reviews can be prepared or conducted earlier if exceptional circumstances apply

• The MBS fees for planning (new GPCCMP) and review items are equalised. The fee for preparation or review is $156.55 for GPs and $125.30 for Prescribed Medical Practitioners (PMPs)
• Previously, the rebate for a GPMP (items 721, 92024) was $164.35, for TCAs (items 723, 92025) was $130.25, and a review (item 732, 92028) was $82.10
• The impact on annual funding for chronic disease management will depend on the billing approach for each patient
• If no changes are made to the frequency or composition of services (i.e., only billing one item for plan creation), there could be a reduction in the billing. This is largely due to the new item 965 replacing both the old 721 and 723, which previously could both be billed for the same patient in certain circumstances
• Practitioners may be able to increase billings by completing additional reviews, as these now carry an equalised incentive. For example, a change from one new plan and one review to two reviews could result in a slight increase in billings
• 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. Consistent with current arrangements, items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items

• New GP items: 965 (prepare face-to-face), 92029 (prepare video), 967 (review face-to-face), 92030 (review video)
• New PMP items: 392 (prepare face-to-face), 92060 (prepare video), 393 (review face-to-face), 92061 (review video)
• The ceased items are replaced with new items for GPs and PMPs to prepare and review GPCCMPs
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers can assist the GP or prescribed medical practitioner to prepare or review a GPCCMP, with this assistance formally specified in the regulatory arrangements for the new items
• These new items apply to both face-to-face and telehealth (video) services with fees of $156.55 for GPs and $125.30 for PMPs
• Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled, while patients not registered with MyMedicare can access these services at any practice but should use their usual GP
• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance MBS items

• GPCCMP telehealth items available: 92029 (GP prepare), 92030 (GP review), 92060 (PMP prepare), 92061 (PMP review)
• GPCCMP telehealth items are NOT subject to the established clinical relationship rule that applies to most general practice telehealth items
• Instead, GPCCMP telehealth items are subject to the same MyMedicare and usual medical practitioner requirements as the face-to-face GPCCMP items
• Patients registered with MyMedicare must access GPCCMP telehealth items through the practice where they are enrolled, while patients not registered with MyMedicare can access these services at any practice but should use their usual GP
• The regulations define "usual medical practitioner" as a GP or PMP who: (1) has provided the majority of services to the person in the past 12 months; OR (2) is likely to provide the majority of services to the person in the following 12 months; OR (3) is located at a medical practice that has provided (or is likely to provide) the majority of services to the person in the past/next 12 months
• Consistent with general telehealth rules, GPCCMP telehealth items cannot be used when the patient is an admitted patient of a hospital
• The fees are the same as face-to-face items: $156.55 for GPs, $125.30 for PMPs

• Standard timing rules: GPCCMP can be prepared once every 12 months (and any new plan must be at least 3 months after the last review), and reviewed once every 3 months
• Exceptional circumstances allow earlier services when there has been a significant change in the patient's clinical condition or care circumstances that necessitates the performance of the service
• The particulars of the exceptional circumstances should be documented in the patient's record to substantiate the claim
• Services Australia needs to be advised that exceptional circumstances apply to pay a benefit sooner than generally allowable
• To facilitate payment, the patient's invoice, Medicare voucher or digital claim should indicate that exceptional circumstances apply - no further explanation is required to support payment
• Example scenario: A patient has a GPCCMP for asthma that was reviewed 1 month ago, then gets diagnosed with type 1 diabetes. You can review their plan (or develop a new plan) as a priority due to exceptional circumstances
• There is no minimum amount of time required to spend with the patient, but all MBS requirements must be met including that the GP or PMP must attend the patient, discuss the plan, and ensure the patient understands and agrees with it

• 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
• The ceased items are replaced with new items for GPs and PMPs to prepare and review GPCCMPs
• New GP items: 965 (prepare face-to-face), 92029 (prepare video), 967 (review face-to-face), 92030 (review video)
• New PMP items: 392 (prepare face-to-face), 92060 (prepare video), 393 (review face-to-face), 92061 (review video)

• From 1 July 2025, GP management plans (229, 721, 92024, 92055) and team care arrangements (230, 723, 92025, 92056) ceased
• Reviews (233, 732, 92028, 92059) also ceased on 1 July 2025
• MBS items for reviewing GPMPs and TCAs ceased on 1 July 2025 - if a patient requires a review of their GPMP and/or TCA after 1 July 2025 they should be transitioned to a new GP chronic condition management plan (GPCCMP)
• From 1 July 2025, any new plans put in place will need to meet the requirements of a GPCCMP
• Patients with GPMPs and/or TCAs in place prior to July 1, 2025, can continue to access services consistent with those plans during a transition period until June 30, 2027
• Individual and group allied health services can be accessed under existing GPMPs and TCAs until June 30, 2027
• Referrals for allied health services written prior to 1 July 2025, will remain valid until all services under that referral have been provided
• From 1 July 2027, a GPCCMP will be required for ongoing access to MBS-funded allied health services and domiciliary medication management reviews (items 245 and 900)

• The MBS fee to prepare a GPCCMP is $156.55 for GPs and $125.30 for PMPs
• The fee for reviewing a GPCCMP is the same: $156.55 for GPs and $125.30 for PMPs
• Previously, the rebate for preparation of a GPMP (MBS Items 721, 92024) was $164.35, preparation of TCAs (MBS Items 723, 92025) was $130.25 and a review (MBS Item 732, 92028) was $82.10
• The new Medicare fee is the same for the preparation and the review of a plan
• To encourage reviews and ongoing care, the MBS fees for planning and review items have been equalised
• 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

• Items for preparing a GPCCMP can be claimed every 12 months if clinically relevant
• GPCCMP reviews are available every 3 months if clinically relevant
• Plans may be prepared or reviewed earlier if exceptional circumstances apply
• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day 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)
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers can assist the GP or prescribed medical practitioner to prepare or review a GPCCMP, but cannot claim item 10997 for their assistance time as GPCCMP items are complete medical services
• Co-claiming GPCCMP items with practice nurse services (10997, 93201, 93203) IS appropriate when the practice nurse provides a separate, clinically relevant service consistent with the patient's plan. Examples include:
• Review and wound treatment: GP reviews GPCCMP (item 967) and practice nurse dresses diabetic wound (item 10997) on same day
• Plan/review and immunisation: GP prepares GPCCMP (item 965) and practice nurse administers vaccine (item 10997) on same day
• Review and parenteral medication: GP reviews GPCCMP (item 967) and practice nurse administers B12 injection or denosumab (item 10997) on same day
• 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
• It is not required that a new plan be prepared each year; existing plans can continue to be reviewed

• Providers are responsible for ensuring services claimed from Medicare using their provider number meet all legislative requirements and may be required to submit evidence for compliance checks related to Medicare claims
• Practitioners should ensure they keep adequate and contemporaneous records (see GN.15.39 for guidance on what constitutes adequate and contemporaneous records)
• Where a GPCCMP item specifies the creation of a document, that document must be retained for 2 years as specified in Clause 4.3 of the Health Insurance Act 1973
• The GP or prescribed medical practitioner must attend the patient, have a discussion with them about the plan, and be satisfied that the patient understands and agrees with the plan (including actions they are to take), even if staff have assisted in preparing or reviewing the plan
• Hospital-employed practitioners have restrictions: GPCCMP items can only be used by medical practitioners who are either (1) not employed by the proprietor of a hospital that is not a private hospital, OR (2) employed by such a hospital but providing the service outside the course of that employment
• Nurse practitioners can provide item 10997 services as they meet the definition of a practice nurse, provided they're working in general practice or a health service with a relevant section 19(2) exemption

• GPCCMP items may be claimed with single bulk billing incentives when eligible patients are bulk billed
• GPCCMPs will be included in the Bulk Billing Practice Incentive Program from 1 November 2025
• When you bulk bill eligible patients for GPCCMP services, you can claim bulk billing incentives as part of the government's broader commitment to supporting bulk billing
• The Bulk Billing Practice Incentive Program inclusion represents additional financial support beyond the current single bulk billing incentives

• A GPCCMP can be prepared once every 12 months, if clinically relevant
• Reviews can be conducted once every 3 months, if clinically relevant
• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers can assist the GP or prescribed medical practitioner to prepare or review a GPCCMP

• GPCCMP reviews can be conducted every 3 months, if clinically relevant
• Unless exceptional circumstances apply, reviews can be conducted once every 3 months

• From 1 July 2025, the existing MBS items for GPMPs (229, 721, 92024, 92055), team care arrangements (230, 723, 92025, 92056), and their review items (233, 732, 92028, 92059) will cease
• Any new plans put in place from 1 July 2025 will need to meet the requirements of a GPCCMP
• If a patient requires a review of their existing GPMP or TCA after 1 July 2025, they should be transitioned to a new GPCCMP
• Patients with GPMPs and/or TCAs in place prior to 1 July 2025 can continue to access services consistent with those plans during a transition period until 30 June 2027
• The Department of Health, Disability and Ageing have advised:

• During this transition period (until 30 June 2027), individual and group allied health services can still be claimed under existing GPMPs and TCAs, and medical practitioners can continue to write referrals under these plans
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP
• The fee for the preparation or review of a plan will be $156.55 for GPs and $125.30 for prescribed medical practitioners
• 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
• Referrals for allied health services written prior to 1 July 2025 will remain valid until all services under that referral have been provided
• From 1 July 2027, a GPCCMP will be required for ongoing access to MBS-funded allied health services and domiciliary medication management reviews (items 245 and 900)

• For patients that have a GPMP and/or TCA in place prior to 1 July 2025 there is no immediate action required
• Patients can continue to access allied health and other services under their existing plans until 30 June 2027
• Patients can continue to access services provided through MBS item 10997 (and its telehealth equivalents 93201 and 93203) under existing GPMPs and TCAs until 30 June 2027
• Individual and group allied health services can be accessed under existing GPMPs and TCAs until 30 June 2027
• Medical practitioners can continue to write referrals under these existing plans until 30 June 2027, but any new referrals written from 1 July 2025 must meet the new referral requirements (letters instead of forms)
• Referrals written prior to 1 July 2025 will continue to be valid until all services under that referral have been provided
• MBS items for reviewing GPMPs and TCAs will cease on 1 July 2025
• 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
• The Department of Health, Disability and Ageing have advised:

• From 1 July 2027 patients will require a GPCCMP to continue to access allied health and other services

• Any new plans put in place from 1 July 2025 will need to meet the requirements of a GPCCMP
• Any new referrals for allied health services should meet the new referral requirements that come into effect on 1 July 2025, regardless of whether the referral is made under a GPMP, TCA or GPCCMP
• MBS items for reviewing GPMPs and TCAs will cease on 1 July 2025 - if a patient requires a review after 1 July 2025 they should be transitioned to a new GPCCMP
• The Department of Health, Disability and Ageing have advised: "While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant"
• Unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months if clinically relevant; GPCCMP reviews are available every 3 months if clinically relevant
• Plans may be prepared or reviewed earlier if exceptional circumstances apply
• To maintain access to MBS-funded allied health services, a GPCCMP must have been prepared or reviewed in the previous 18 months
• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
• The fee for the preparation or review of a plan will be $156.55 for GPs and $125.30 for prescribed medical practitioners

• MBS items for reviewing GPMPs (233, 732, 92028, 92059) and TCAs will cease on 1 July 2025
• If a patient requires a review of their GPMP and/or TCA after 1 July 2025 they should be transitioned to a new GP chronic condition management plan (GPCCMP)
• The Department of Health, Disability and Ageing have advised: "While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant"
• For patients that have a GPMP and/or TCA in place prior to 1 July 2025 there is no immediate action required
• Patients can continue to access allied health and other services under their existing plans until 30 June 2027
• The new MBS items to review a GPCCMP should only be used to review an existing GPCCMP - if a patient requires a review of a GPMP or TCA that was put in place prior to 1 July 2025 they should be transitioned to the new arrangements through the preparation of a GPCCMP
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare the new GPCCMP

• When a patient requires a review of an existing GPMP or TCA after 1 July 2025, they should be transitioned to the new GPCCMP by preparing a new plan
• Preparing a GPCCMP involves creating a written plan that describes: the patient's chronic condition(s) and associated healthcare needs; health and lifestyle goals developed collaboratively by the patient and the 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 required, the services the medical practitioner will refer the patient to, including the purposes of those treatments or services; arrangements for reviewing the plan, including a proposed timeframe for review
• The process must also include: recording the patient's consent and agreement to the plan's preparation; offering a copy of the plan to the patient and their carer (if appropriate and consented to by the patient); adding a copy of the plan to the patient's medical records
• The Department of Health, Disability and Ageing have advised:

• If referring to a multidisciplinary team member, the GP or PMP must obtain the patient's consent to share relevant information and provide relevant parts of the plan in addition to the referral
• Allied health providers do not need to confirm acceptance of the referral or provide input into plan preparation, but they are still required to send written reports back to the GP after certain services (e.g., the first service)
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP

• Referrals for allied health services written prior to 1 July 2025 will remain valid until all services under the referral have been provided
• Any new referrals for allied health services should meet the new referral requirements that come into effect on 1 July 2025, regardless of whether the referral is made under a GPMP, TCA or GPCCMP
• Individual and group allied health services can be accessed under existing GPMPs and TCAs until 30 June 2027
• Medical practitioners can continue to write referrals under existing plans until 30 June 2027, but any new referrals written from 1 July 2025 must meet the new referral requirements (letters instead of forms)
• 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
• 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

• Patients can continue to access services provided through MBS item 10997 (and its telehealth equivalents 93201 and 93203) under existing GPMPs and TCAs until 30 June 2027
• From 1 July 2027, a GPCCMP will be required for ongoing access to MBS-funded allied health and related services
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP under the new framework
• The nature of the services that can be provided using items 10997, 93201, 93203 are not changing as part of these reforms
• To remain eligible for these services, patients (other than those covered by the transition arrangements) will have to have had their GPCCMP prepared or reviewed in the previous 18 months

• Patients can access up to 5 individual allied health services per calendar year where these services are consistent with their GPCCMP
• For patients of Aboriginal or Torres Strait Islander descent, this entitlement is up to 10 services per calendar year
• Patients' eligibility for services is reset on 1 January every year automatically - they are not required to review their plan to enable services or otherwise reset the count, provided patients continue to meet the eligibility requirements for the service
• Unused services do not rollover - patients are eligible for up to 5 services per calendar year regardless of any prior claiming patterns
• Patients with GPMPs and/or TCAs in place prior to 1 July 2025 can continue to access individual and group allied health services under those existing plans until 30 June 2027
• To continue to access allied health services beyond this transition period (or for any new plan after July 1, 2025), a GPCCMP must have been prepared or reviewed in the previous 18 months
• The nature of the individual and group allied health services that can be provided under the chronic condition management arrangements are not changing as part of these reforms, but the item descriptors have changed due to the removal of GPMPs and TCAs and commencement of GPCCMPs

• 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
• The Regulations define "usual medical practitioner" as: "a general practitioner or prescribed medical practitioner: 1. who has provided the majority of services to the person in the past 12 months; or 2. who is likely to provide the majority of services to the person in the following 12 months; or 3. located at a medical practice that: a. has provided the majority of services to the person in the past 12 months; or b. is likely to provide the majority of services to the person in the next 12 months"
• These requirements are the same for face to face and telehealth items
• Telehealth items (92029, 92030, 92060, 92061) are not subject to the established clinical relationship rule that applies to most general practice telehealth items
• Instead, telehealth GPCCMP items are subject to the same MyMedicare and usual medical practitioner requirements as the face-to-face items
• To support continuity of care, patients registered through MyMedicare will be required to access the GP chronic condition management plan and review items through the practice where they are registered

• 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 at any practice
• The Regulations define "usual medical practitioner" as: "a general practitioner or prescribed medical practitioner: 1. who has provided the majority of services to the person in the past 12 months; or 2. who is likely to provide the majority of services to the person in the following 12 months; or 3. located at a medical practice that: a. has provided the majority of services to the person in the past 12 months; or b. is likely to provide the majority of services to the person in the next 12 months"
• These requirements are the same for face to face and telehealth items

• Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled
• Patients who are not registered may access the services through their usual GP
• Patients can change their MyMedicare registration to a different practice if they choose

• To support continuity of care, patients registered through MyMedicare will be required to access the GP chronic condition management plan and review items through the practice where they are registered
• Patients who are not registered may access the services through their usual GP at any practice
• The framework supports continuity of care and plays a role in long-term care planning

• Patients that are not registered may access the services through their usual GP
• The Regulations define "usual medical practitioner" as: "a general practitioner or prescribed medical practitioner: 1. who has provided the majority of services to the person in the past 12 months; or 2. who is likely to provide the majority of services to the person in the following 12 months; or 3. located at a medical practice that: a. has provided the majority of services to the person in the past 12 months; or b. is likely to provide the majority of services to the person in the next 12 months"

• 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
• The Regulations define "usual medical practitioner" as: "a general practitioner or prescribed medical practitioner: 1. who has provided the majority of services to the person in the past 12 months; or 2. who is likely to provide the majority of services to the person in the following 12 months; or 3. located at a medical practice that: a. has provided the majority of services to the person in the past 12 months; or b. is likely to provide the majority of services to the person in the next 12 months"
• Patients can change their MyMedicare registration to a different practice

• From 1 July 2025, referral forms will no longer be used for allied health services; instead, referral letters will be used, consistent with the referral process for medical specialists
• The requirement for a GP or prescribed medical practitioner to consult with at least two collaborating providers in the development of a patient's plan has been removed
• GPs and prescribed medical practitioners will refer patients with a GPCCMP directly to relevant services
• Allied health providers do not need to confirm acceptance of the referral or 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 from the date of the first service provided under the referral
• These new referral requirements apply to all allied health referrals under the chronic conditions management framework, as well as some other MBS-supported allied health services including Group M3 (subgroup 1), Group M8, Group M9, Group M10 (subgroup 1), and Group M11
• Referrals for allied health services written prior to 1 July 2025 will remain valid until all services under that referral have been provided

• The requirement for a GP or prescribed medical practitioner to consult with at least two collaborating providers in the development of a patient's plan has been removed
• GPs and prescribed medical practitioners will refer patients with a GPCCMP directly to relevant services
• Allied health providers do not need to confirm acceptance of the referral or provide input into the preparation of the GPCCMP
• Collaboration with members of the patient's multidisciplinary team will no longer be required in the development of the plan
• The changes aim to simplify, streamline, and modernise the arrangements for health professionals

• From 1 July 2025, referral forms will no longer be used for allied health services; referral letters will be used, consistent with the referral process for medical specialists
• The requirements for referrals to allied health professionals are set out in the Health Insurance (Section 3C – Allied Health Services) Determination 2024 (Allied Health Determination) and mirror those for referrals to medical specialists
• To be valid, a referral letter must include: the name of the referring practitioner; the address of the practice, or the practitioner's provider number at that practice; the date on which the referring practitioner made the referral; the validity of the referral (if relevant); be in writing; be signed by the referring practitioner (which may be by electronic signature); be dated; explain the reasons for referring the patient, including any information about the patient's condition that the referring practitioner considered necessary to give the allied health professional
• For referrals to individual or group allied health services (Group M3 Subgroup 1, Group M9 and Group M11) referrals will be valid for 18 months from the date of the first service provided under the referral, unless otherwise specified by the referring practitioner
• Referrals do not need to specify the name of the allied health provider to provide the services
• Referrals do not need to specify the number of services to be provided; however, referring medical practitioners can still specify the number of services if they choose to do so

• Referrals do not need to specify the name of the allied health provider to provide the services
• Referrals do not need to specify the number of services to be provided
• However, nothing prevents the referring medical practitioner from specifying the number of services to be provided under the referral, if they choose to do so
• One of the objectives of the changes is to provide patients with greater choice and flexibility
• The patient can take the referral to any eligible allied health professional of the same profession/type specified in the referral of their choosing
• Acceptance of a referral is at the discretion of the individual practitioner, subject to anti-discrimination legislation
• This recognises that some patients accessing allied health services may wish to access a higher number of services than are supported by the MBS

• Referrals can be signed and transmitted electronically
• The Electronic Transactions Act 1999 allows for documents required under Commonwealth Law, such as referrals under the Allied Health Determination, to be signed and transmitted electronically
• Where the intended allied health provider is known, referring practitioners are encouraged to send referrals electronically where possible to minimise the risk of lost referrals
• Electronic signatures are acceptable for referral signing requirements

• 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 from the date of the first service provided under the referral
• For referrals to individual or group allied health services (Group M3 Subgroup 1, Group M9 and Group M11) referrals will be valid for 18 months from the date of the first service provided under the referral, unless otherwise specified by the referring practitioner
• These timeframes are measured from the date the first service is provided under the referral, not the date of the referral
• This aligns with the requirement for patients with a GP chronic condition management plan to have had their plan put in place or reviewed within the last 18 months to continue to access services
• For specialist services the default referral length is 12 months from the date of the first service provided under the referral (for comparison)
• Referrals to allied health professionals cannot be indefinite referrals

• There is no requirement for allied health providers to confirm acceptance of the referral or 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
• Requirements for allied health providers to report back to the referring practitioner at certain points (e.g. after the first and last service under a referral) have not changed
• Acceptance of a referral is at the discretion of the individual practitioner, subject to anti-discrimination legislation

• The new referral requirements apply to all allied health referrals under the chronic conditions management framework, as well as some other MBS-supported allied health services
• As of 1 July 2025, these requirements do not apply to other MBS-supported allied health services, including Better Access psychological therapy services, focussed psychological strategies (allied mental health) services, eating disorder allied health services, or diagnostic audiology services
• These changes do not affect multidisciplinary care plan items
• The new referral requirements apply to: Group M3 (subgroup 1) – individual allied health services for patients with a chronic condition; Group M8 – pregnancy support counselling allied health services; Group M9 – allied health group services for patients with type 2 diabetes; Group M10 (subgroup 1) – complex neurodevelopmental disorders and eligible disabilities allied health services; Group M11 – allied health services for Aboriginal and Torres Strait Islander people

• The nature of the individual and group allied health services that can be provided under the chronic condition management arrangements are not changing as part of these reforms, only the item descriptors are changing due to the removal of GPMPs/TCAs and commencement of GPCCMPs
• Providers are responsible for ensuring services claimed from Medicare using their provider number meet all legislative requirements and they may be required to submit evidence for compliance checks related to Medicare claims

• Providers are responsible for ensuring services claimed from Medicare using their provider number meet all legislative requirements and they may be required to submit evidence for compliance checks related to Medicare claims
• Practitioners should ensure they keep adequate and contemporaneous records

• A GPCCMP can be prepared once every 12 months, if clinically relevant, unless exceptional circumstances apply
• It is not required that a new plan be prepared each year; existing plans can continue to be reviewed
• GPCCMP reviews can be conducted once every 3 months, if clinically relevant, unless exceptional circumstances apply
• To maintain access to MBS-funded Allied Health Services, a GPCCMP must have been prepared or reviewed in the previous 18 months
• 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 fee to prepare a GPCCMP is $156.55 for GPs and $125.30 for PMPs
• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items

• GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care
• A chronic medical condition must have been (or is likely to be) present for at least 6 months or is terminal
• There is no list of eligible conditions - 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
• GPCCMPs are not available to patients who are care recipients in a residential aged care facility - allied health services are available to these patients through a multidisciplinary care plan
• For face-to-face items only, patients can be an in-patient of a private hospital - patients that are public in-patients of a hospital are not eligible for these services
• Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled; patients who are not registered must access GPCCMP items through their usual GP

• 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 (including the purposes of those treatments or services)
• 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 preparation of the plan
• Offering a copy of the plan to the patient and their carer (if any, and if appropriate and the patient agrees)
• Adding a copy of the plan to the patient's medical records
• A practice nurse, Aboriginal and Torres Strait Islander Health Practitioner or Aboriginal Health Worker may assist with the development or review of a plan

• The process of developing and finalising a GPCCMP must include recording the patient's consent and agreement to the preparation of the plan
• If the patient is to be referred to a member of 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
• The process of reviewing a GPCCMP must also include recording the patient's consent and agreement to the updates made to the plan

• Subject to the patient's consent, GPs and PMPs are encouraged to upload the GPCCMP to My Health Record
• Upload is not a requirement of the MBS item, so it is not essential that the plan be uploaded prior to submitting an MBS claim

• Patients can access the following MBS-supported services where they are consistent with their GPCCMP:
• Up to 5 individual allied health services per calendar year (with 10 services available for patients of Aboriginal or Torres Strait Islander descent)
• Up to 5 services provided on behalf of a medical practitioner by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner (Fee: $14.00 Benefit: 100% = $14.00 for item 10997)
• For patients with type 2 diabetes, an assessment of their suitability for group dietetics, diabetes education or exercise physiology services, and if suitable, up to 8 group services for the management of diabetes per calendar year
• Aboriginal and Torres Strait Islander health services using MBS items 10950, 81300, 93000, 93013, 93048 and 93061
• Where multidisciplinary care is required, patients will be able to access the same range of services currently available through GP management plans and team care arrangements
• 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

• Patients can access up to 5 individual allied health services per calendar year (with 10 services for patients of Aboriginal or Torres Strait Islander descent)
• For patients with type 2 diabetes, up to 8 group services for diabetes management are provided per calendar year
• Patient eligibility is reset on 1 January every year automatically - you are not required to review their plan to enable services or otherwise reset the count
• Unused services do not rollover - patients are eligible for up to 5 services per calendar year regardless of any prior claiming patterns

• Patients will be eligible for the plan if their condition is managed by their GP or prescribed medical practitioner, whether or not multidisciplinary care is required
• A GPCCMP is for patients with one or more chronic medical conditions who would benefit from a structured approach to their care
• The plan is intended to be a patient-centred plan - while there are a range of MBS-supported services available for patients with a GPCCMP, services that are supported through other funding mechanisms can also be identified in the plan

• There is nothing that precludes the inclusion of activities or services that are not covered by MBS funding arrangements, such as social prescribing
• The GPCCMP is intended to set out the agreed actions and services that would be beneficial to the patient in managing their chronic condition
• It is important that patients are aware when services that are not supported by the MBS are included in their plan
• While there are a range of MBS-supported services available for patients with a GPCCMP, services that are supported through other funding mechanisms can also be identified in the plan

• GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care
• The written plan must describe the patient's chronic condition(s) and associated health care needs
• The plan is intended to be a patient-centred plan, and while it supports MBS-funded services, services supported through other funding mechanisms can also be identified in the plan
• If the patient would benefit from multidisciplinary care, the plan should identify the services the medical practitioner will refer the patient to. A member of the multidisciplinary team is a person who provides treatment or service to the patient and provides a different kind of treatment or service than each other member
• The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs - consultation with at least two collaborating providers is no longer required

• GPCCMPs can be prepared and reviewed by GPs and prescribed medical practitioners either face to face, or via video
• New MBS item numbers are available for both face-to-face and telehealth (video) services for developing a GPCCMP (965, 392 face-to-face; 92029, 92060 video) and reviewing a GPCCMP (967, 393 face-to-face; 92030, 92061 video)
• Telehealth items are not subject to the established clinical relationship rule that applies to most general practice telehealth items - instead, they are subject to the same MyMedicare and usual medical practitioner requirements as the face-to-face items
• Consistent with general telehealth rules, telehealth items cannot be used when the patient is an admitted patient of a hospital
• GPCCMP services can be provided to a patient in a hospital, but only by medical practitioners who are not employed by the proprietor of a hospital that is not a private hospital, or is employed by such proprietor and provides the service otherwise than in the course of employment

• Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled. These requirements apply to both face-to-face and telehealth items
• Patients who are not registered with MyMedicare may access GPCCMP services through their usual GP
• "Usual medical practitioner" is defined in the Regulations as a general practitioner or prescribed medical practitioner:
• Who has provided the majority of services to the person in the past 12 months; or
• Who is likely to provide the majority of services to the person in the following 12 months; or
• Located at a medical practice that has provided the majority of services to the person in the past 12 months or is likely to provide the majority of services in the next 12 months
• The new MBS items to review a GPCCMP should only be used to review an existing GPCCMP - if a patient requires a review of their GPMP or TCA that was put in place prior to 1 July 2025, they should be transitioned to the new GPCCMP at that time through the preparation of a new GPCCMP

• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist a GP or prescribed medical practitioner in preparing or reviewing a GPCCMP
• The GPCCMP is a plan between the GP/prescribed medical practitioner and their patient - it is a requirement that the GP/prescribed medical practitioner sees the patient as part of the service, and they are responsible for the service
• The changes recognise the importance of practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers in the management of chronic conditions within primary care

• GPCCMP items may be billed by General Practitioners and Prescribed Medical Practitioners only
• The clinical roles authorised to assist a GP or prescribed medical practitioner in preparing or reviewing a GPCCMP include Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers
• The ability for these roles to assist has been specified in the regulatory arrangements for the new items
• It is a requirement that the GP/prescribed medical practitioner sees the patient as part of the service, and they are responsible for the service
• The items for preparing and reviewing a GPCCMP are complete medical services - they provide the full MBS benefit for the services
• Practice nurses are defined as "a registered or an enrolled nurse who is employed by, or whose services are otherwise retained by, a general practice"
• Nurse practitioners are registered nurses with an endorsement - provided they are working in general practice, they meet the definition of a practice nurse for these items

• There is no minimum amount of time required to spend with the patient when staff assist with GPCCMP preparation or review
• All MBS requirements must be met including that the GP or prescribed medical practitioner must attend the patient, have a discussion with them about the plan, and be satisfied that the patient understands and agrees with the plan (including actions they are to take)
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist the GP or prescribed medical practitioner in preparing or reviewing a GPCCMP
• Several factors determine how long the consultation will take, including the complexity of their condition(s), whether this is the patient's first plan, whether their condition is stable or has changed significantly, and whether their treatment goals remain the same

• The process of developing and finalising a GPCCMP must include adding a copy of the plan to the patient's medical records
• The process of reviewing a GPCCMP must include adding a copy of the updated plan to the patient's medical records
• Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist a GP or prescribed medical practitioner in preparing or reviewing a GPCCMP
• Providers are responsible for ensuring services claimed from Medicare using their provider number meet all legislative requirements and they may be required to submit evidence for compliance checks
• Practitioners should ensure they keep adequate and contemporaneous records

• Review and wound treatment (e.g., diabetic wounds) - where the nurse provides separate wound care on the same day
• Plan/review and immunisation - where the nurse administers vaccines identified in the GPCCMP
• Plan/review and administration of parenteral medication (e.g., B12 injection) - where separate medication administration occurs

• Item 10997 (and its telehealth equivalents) cannot be used when a practice nurse or Aboriginal and Torres Strait Islander health practitioner assists with the preparation or review of a GPCCMP
• The items for preparing and reviewing a GPCCMP are complete medical services and provide the full MBS benefit for the services - you cannot co-claim a second item for the provision of these services
• Co-claiming may be appropriate where the service provided by the practice nurse or Aboriginal and Torres Strait Islander health practitioner is separate from, but consistent with the patient's plan development or review
• Examples of appropriate co-claiming scenarios include:
• Review and wound treatment (e.g., diabetic wounds) - where the nurse provides separate wound care on the same day
• Plan/review and immunisation - where the nurse administers vaccines identified in the GPCCMP
• Plan/review and administration of parenteral medication (e.g., B12 injection) - where separate medication administration occurs

• Practices are encouraged to provide training for GPs, practice nurses, and other relevant staff on the new chronic condition management plan requirements and referral processes
• Practices can seek support and resources from their local Primary Health Networks (PHNs) to assist with the transition and participate in available training or informational sessions

• Patients with a GPCCMP will be able to access services provided by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner on behalf of a medical practitioner using items 10997, 93201 and 93203
• 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
• There are changes to the item descriptors for these items due to the removal of GPMPs and TCAs, and commencement of GPCCMPs
• The nature of the services that can be provided using items 10997, 93201, 93203 are not changing as part of these reforms
• Patients are eligible for up to 5 services per calendar year in total - the 5 services can be made up of any combination of 93201, 93203 and 10997
• Fee: $14.00 Benefit: 100% = $14.00 for item 10997 (face-to-face services)

• 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
• 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
• 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
• 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
• 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
• 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
• 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
• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items

• Cubiko includes a pop-out view that can sit alongside your PMS, showing whether a patient is registered or eligible to register for MyMedicare
• Care Prompts can be sent directly to the Best Practice appointment book to prompt conversations between practitioners and patients about GPCCMP services
• 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
• Key Cubiko metrics for GPCCMP management include:
• Possible Service Opportunities Today - identifies patients with appointments today who may be eligible for GPCCMP services
• Cancelled Appointments - tracks patients who have cancelled GPCCMP appointments and may need rebooking
• Appointments to rebook - identifies patients who attended but haven't booked follow-up appointments
• Recalls and Recall appointments to rebook - provides insight into outstanding recall types
• Cubiko dashboards can track CCMP delivery, spot trends and address workflow gaps to support continuous improvement
• Regular audits can identify patients due for GPCCMPs, reviews, immunisations or screenings using integrated data

• Internal references in the existing system GPMP and TCA templates will be updated with GPCCMP terminology
• New Word Processor templates will be provided for the GPCCMP Plan and GPCCMP Allied Health Referral Letter
• 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

• 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
• 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
• 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
• The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs - consultation with at least two collaborating providers is no longer required

• New appointment types will be introduced to support patient recall and documentation for GPCCMP related appointments: GPCCMP Plan and GPCCMP Plan Review
• Appointments should be scheduled within the next two weeks following a patient's appointment to support timely and continuous care
• 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

• Cubiko offers a range of resources to help your team explain the value of MyMedicare in a clear and confident way, including:
• A step-by-step MyMedicare registration workflow
• Printable MyMedicare Educational posters for the waiting room
• Webinar recordings covering key details, benefits and how to engage patients in registration
• Integrated tools can identify patients who are eligible but not yet registered for MyMedicare through:
• MyMedicare eligible patients with an appointment today
• Upcoming telehealth patients who are not MyMedicare registered
• Pop-out views can sit alongside your PMS, showing whether a patient is registered or eligible to register for MyMedicare
• SMS messaging capabilities allow you to download patient lists and send registration information directly

• Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
• Future versions of Practice Management Systems, such as Bp Premier, will support validation for co-claiming rules
• This functionality is designed to reduce billing errors, support compliance, and streamline claim processing
• 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)

• 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
• 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
• The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs - consultation with at least two collaborating providers is no longer required

• 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)

• 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

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.