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Request is made for reimbursement of supplemental benefits paid during the preceding calendar year under the provisions of s.102. CJP Quarterly Reimbursement Request Form.Upper Payment Limit are supplemental payments to hospitals that have always been restricted to fee-for-service payments. Any public EMS provider that meets the Qualified Provider criteria. PRE-APPROVAL AND REQUEST FOR PAYMENT FOR SUPPLEMENTARY SERVICE. FQHC and RHC Medical Supplemental Payment Claim. CJP Quarterly Reimbursement Request Form. Total income from IUP cannot exceed the limits of the PASSHE Compensation Policy. PRE-APPROVAL AND REQUEST FOR PAYMENT FOR SUPPLEMENTARY SERVICE. CJP Quarterly Reimbursement Request Form.