Technical Assessment Forms


Download Technical Assessment Forms (PDF)

TA Form Required Test
GEN-CQ-003
Technical Assessment Submission Checklist
Page 1
(previously M00151)
All tests submitting a Technical Assessment
GEN-CQ-003
Technical Assessment Submission Checklist
Page 2
(previously M00151)
NGS “Comprehensive Genomic Profile”
Tests based on novel or proprietary technology and/or algorithms
Whole Exome Sequencing
Whole Genome Sequencing
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 Germline Testing
(previously M00155)

NGS Germline tests
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
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: 09/08/2021