Technical Assessment Forms


Download Technical Assessment Forms (PDF)

TA Form Required Test

GEN-CQ-003
Technical Assessment Submission Checklist
(previously M00151)

UPDATED on 01/06/2022

All tests submitting a Technical Assessment

GEN-PF-001
Technical Assessment (TA) Summary Form
(previously M00116)
NGS tests with results that are either novel or proprietary technology and/or algorithms. Reserved for tests that require an evaluation of clinical utility or clinical validity that is not already established in existing policies or standards of care.
NGS-PF-004
Analytical Validity, Clinical Validation Summary Worksheet, NGS Solid Tumors
(previously M00153)
NGS “Targeted” Panel described by 81445
NGS “Comprehensive Genomic Profile” – Solid Tumor
NGS-PF-005
Analytical Validity, Clinical Validation Summary Worksheet, Myeloid Malignancies
(previously M00154)
NGS “Targeted" Panel described by 81450
NGS “Comprehensive Genomic Profile” – Hematopoietic malignancy

NGS-PF-006

 Analytical Validity, Clinical Validation Summary Worksheet, NGS in Hereditary Cancer Testing
(previously M00155)

UPDATED on 01/06/2022

Hereditary Cancer Testing

NGS-PF-002
Analytical Validity – Performance Specifications for Comprehensive Genomic Profiling Checklist, Somatic and Germline
(previously M00119)
NGS “Comprehensive Genomic Profile” – Solid Tumor NGS “Comprehensive Genomic Profile” – Hematopoietic malignancy Whole Exome Sequencing Whole Genome Sequencing

MRD-PF-016
 Analytical Validity, Clinical Validity Summary Worksheet, MRD

NEW as of 01/06/2022

Minimial Residual Disease (MRD) Testing

PGX-PF-007
Pharmacogenomics Submission Form
(previously M00156)
Pharmacogenomics (PGx) tests
ALLO-CQ-003
Technical Assessment Submission Checklist and Questionnaire for Solid Organ Allograft Rejection
(previously M00159)
Molecular Testing for Solid Organ Allograft Rejection
ALLO-PF-009
Allograft Rejection Performance
(previously M00160)
Molecular Testing for Solid Organ Allograft Rejection
GEN-PF-010
Gapfill Worksheet
Required for tests that must be priced by Palmetto GBA.

 





Last Updated: 01/06/2022