GP referrals for Medicare claims
A current, valid GP referral sits behind almost every Medicare claim Praxi submits on your behalf. If the referral is missing, expired, or doesn't match the rendering practitioner, Services Australia rejects the claim with a referral-required error. This page covers which items need a referral, how Praxi captures referral metadata, the validity rules that govern when SA will accept the claim, and the workflow when a referral expires mid-treatment.
Which items need a referral
Almost all Medicare items Praxi practitioners bill require a referral. The referral document and the eligibility scheme behind it differ by item series:
| Item series | Referral required | Scheme |
|---|---|---|
| 80000–80175 (Better Access) | GP-issued written referral + Mental Health Care Plan (MHCP) | Better Access (MHCP) |
| 10960, 10968, 10970 (EPC) | GP-issued CDM care plan referral | Chronic Disease Management |
| 91167, 91182 (telehealth) | Same as the underlying in-person item | Better Access (telehealth) |
| Specialist consultation items | Referral from another medical practitioner | Various |
Group items (80020, 80125, 80170) carry the same referral requirements as their individual counterparts — each group attendee needs their own current MHCP and referral.
MHCP and referral letter — distinct documents
For Better Access claiming, two documents must be on file:
The mental health treatment plan (MHCP)
The MHCP is the GP's assessment that establishes the client's eligibility for Better Access. It documents the client's mental health diagnosis, treatment goals, and the GP's referral decision. The MHCP itself does not carry a statutory expiry date — Praxi does not auto-expire plans. The client's annual session count resets on 1 January, but the plan can remain valid across calendar years (the referral letter has its own 12-month validity — see below).
The referral letter
The referral letter is a separate document from the MHCP. It names you (or your practice) as the practitioner receiving the referral, specifies the number of sessions authorised (typically 6 initially), and includes the referring GP's provider number. The referral letter is valid for 12 months from the date of issue.
Both documents must be on file before you submit a Better Access claim. The MHCP establishes scheme eligibility; the referral letter establishes that you're the authorised practitioner.
Capturing a referral in Praxi
Open the client's profile, navigate to Profile → Referrals & Funding, and click New Referral. The form asks for:
- Referring provider name — the GP's full name as it appears on the referral letter.
- Provider number — the GP's Medicare provider number (8 characters, including the location stem and check letter). Praxi validates the format before saving.
- Issue date — the date the GP signed the referral.
- Expiry date — auto-calculated as 12 months from the issue date. You can adjust if the GP specifies a different expiry on the letter.
- Number of sessions authorised — typically 6 for an initial Better Access referral, or "indefinite" for an EPC plan referral.
- Scheme — Better Access, EPC, or specialist. The scheme drives which item series the referral unlocks at claim time.
- Attachment — upload the PDF referral letter. The file is stored as an secure attachment and linked to the referral record.
Once saved, the referral is available to claim against. The client's profile shows the active referral on the Funding & Referrals section with a visual countdown to expiry.
Validity at claim time
Every time you submit a Medicare claim, Praxi checks the referral against the service date — not today's date. The checks are:
- A referral exists for the client, in the relevant scheme.
- The service date is on or after the referral issue date. Backdated sessions before the referral was issued are not claimable.
- The service date is on or before the referral expiry date. Sessions after a referral has lapsed need a new referral on file.
- The session count under the referral hasn't been exhausted. The initial 6 sessions, plus the additional 4 after GP review, give a maximum of 10 Better Access individual sessions per referral cycle.
If any check fails, Praxi blocks the claim at the pre-submission stage with a specific blocker on the Claim Readiness panel. You'll see one of:
- "No active referral for the service date" — no referral on file, or the referral has expired.
- "Referral expired before the service date" — the session was after the referral lapsed.
- "Session limit reached for this referral" — exceeds the authorised session count.
If the claim slips through pre-validation and SA rejects it, the SA reason message will identify the missing or expired referral — see Medicare Claiming Errors.
The 6-session GP review
Better Access referrals authorise an initial 6 sessions. After the sixth session, SA expects the referring GP to provide a written review letter on file before sessions 7–10 are claimed. The review confirms the client remains in active treatment and that the GP is monitoring progress.
Praxi prompts you for the GP review letter when you book the seventh appointment for any client on a Better Access referral. The prompt appears in two places:
- On the appointment booking screen as a soft warning.
- On the Medicare Submit Sheet for session 7 as a hard blocker (you can't submit the claim until the review letter is uploaded).
To upload the review letter, open the client's MHCP card and click GP Letter, then attach the document. The review letter doesn't get its own referral record; it attaches to the existing MHCP and unlocks sessions 7–10.
Initial 6 + 4 additional sessions
The Better Access scheme breaks down as:
| Sessions | Authorisation needed |
|---|---|
| 1–6 | Initial GP referral + MHCP |
| 7–10 | Initial GP referral + GP review letter after session 6 |
Maximum of 10 individual Better Access sessions per calendar year per client. This is a hard cap — the temporary COVID-era extension that allowed sessions 11–20 has ended, and there is no current additional-sessions pathway under the MBS schedule.
Continuing care beyond 10 sessions
If your client reaches the 10-session cap and needs ongoing treatment, the options are:
- Private payment — the client pays out-of-pocket. No Medicare claim is submitted.
- NDIS — if the client has an NDIS plan, mental health work may be billable through that channel (see NDIS Invoicing).
- EPC referral — if the client is also under a CDM care plan, EPC sessions are a separate scheme with their own annual cap.
Praxi blocks Better Access claims that would exceed the 10-session cap — a session-limit rejection — and surfaces the cap status on the Funding & Referrals section of the client's profile.
What to do when a referral expires mid-treatment
If your client has an upcoming session and the referral has expired (or will expire before the session date), the quick recovery is:
- Contact the client and explain a new referral is needed.
- Client books a brief GP consultation. The GP issues a new referral.
- Upload the new referral to Praxi via Profile → Referrals & Funding → New Referral. Set the issue and expiry dates from the new letter.
- Praxi automatically uses the new referral for the next claim.
The new referral starts a fresh session count — sessions claimed against the expired referral don't count against the new one's authorisation window. If the client has already used their full 10 individual sessions for the calendar year, however, the new referral can't unlock additional sessions until the new calendar year starts (1 January).
DVA referral semantics
DVA referrals follow different rules from Medicare:
- Each DVA Allied Health claim needs the appropriate referral details.
- DVA referrals can be issued by a wider range of providers, not just GPs — specialists, hospital discharge teams, and DVA case managers can all issue an allied health referral.
- DVA referrals don't have the same 12-month expiry that Better Access referrals do; some DVA referrals are open-ended for the lifetime of an accepted condition (especially for Gold Card holders).
- White Card holders require an accepted condition code on every claim — the referral must align with one of the client's accepted conditions.
See DVA Claims for the full DVA referral workflow.
EPC referral semantics
EPC (CDM) referrals come from a GP-issued CDM care plan rather than an MHCP. Key differences from Better Access:
- The annual cap is 5 sessions across all allied health providers under the CDM plan, not 10 per practitioner.
- Sessions count down against the combined 5-session cap, not against an individual practitioner's allocation.
- The referral runs for the duration of the care plan, not 12 months from issue.
Praxi handles EPC referrals through the same capture flow as Better Access referrals — set the scheme to "EPC" when creating the referral record.
Cross-references
- Medicare Claiming — full MCOL workflow.
- MBS Item Picker — picking the right item for the service.
- Better Access (MHCP) — full scheme rules.
- Medicare Claiming Errors — referral rejection resolution.
- DVA Claims — DVA referral semantics.
- Funding Sources — how funding categories map to referral requirements.
Verified against the current Praxi product surface, Health Insurance (Allied Health Services) Determination 2014 referral rules, and Department of Health Better Access policy on 2026-06-05.