CCM plans help eligible health professionals coordinate health care for patients with chronic or terminal medical conditions.
You can learn about billing GP chronic condition management plans.
Planning and management items are intended to be provided by the patient’s usual medical practitioner.
The patient’s ‘usual medical practitioner’ means a GP, a recognised prescribed medical practitioner or practitioner at the same practice who:
- has provided most of the care to the patient over the previous 12 months, and/or
- will be providing most of the care to the patient over the next 12 months.
To support continuity of care, patients registered through MyMedicare are required to access the GP chronic condition management plan (GPCCMP) and review items through the practice where they are registered.
You or your delegate can check your eligibility for Medicare benefits through the MBS items online checker in HPOS. You can also call Medicare.
CCM services help you coordinate health care for patients with chronic or terminal medical conditions. These medical conditions are present or are likely to be present for 6 months or longer or are terminal.
You or your delegate can check patient eligibility and claiming conditions in the MBS items online checker in HPOS. You can also call Medicare.
Other health professionals can help eligible practitioners deliver some services, including:
- CCM plan development
- monitoring and support services.
Health professionals can help to prepare, contribute and review CCM plans, including:
- performing patient assessment
- identifying patient needs
- arranging for services.
Eligible practitioners must meet all Medicare item requirements, including:
- reviewing and confirming assessments
- attending the patient.
Learn about the relevant MBS item descriptions, fact sheets and explanatory notes on the MBS Online website.
Practice nurses and Aboriginal and Torres Strait Islander health practitioners can monitor and support CCM plans on behalf of medical practitioners.
They can provide support of up to 5 services per calendar year for a patient who has a current CCM plan.
The service must be:
- provided on behalf of and under the supervision of the eligible practitioner
- consistent with the patient’s CCM plan.
You can lookup patient eligibility for MBS item numbers through the MBS items online checker in HPOS. Learn about MBS item descriptions, fact sheets and explanatory notes at MBS Online website.
You may decide that your patient would benefit from a referral to allied health. They can receive 5 individual services each calendar year.
Referrals under a GPCCMP are valid for the timeframe stated in the referral. If there’s no timeframe stated, they’re valid for 18 months from the first service date provided under the referral.
Learn about allied health referrals for chronic disease health care plans.
You can review a plan once every 3 months. You can provide these services more frequently in exceptional circumstances. For example, when there is a significant change in a patient’s condition.
We suggest that practices call and encourage patients to attend an appointment to review their care plan.
Learn about the relevant MBS item descriptions, fact sheets and explanatory notes on the MBS Online website.