Health care clearinghouses, as integral components of larger organizations, recognize the need to safeguard electronic protected health information (ePHI) from unauthorized access by the larger entity. In adherence to regulatory requirements and best practices, the clearinghouse has established and implemented comprehensive policies and procedures to ensure the confidentiality and security of ePHI within its purview. Clear and specific policies are developed to delineate the protection of ePHI held by the clearinghouse from potential unauthorized access by the larger organization. Implementation of robust access controls to restrict and monitor access to ePHI, ensuring that only authorized individuals within the clearinghouse have appropriate access privileges. Clear segregation of duties is established to prevent unauthorized personnel from accessing ePHI, with access permissions aligned with job responsibilities within the clearinghouse.

Implementation of encryption measures for ePHI, both in transit and at rest, to safeguard against unauthorized interception or access.

Utilization of audit and monitoring systems to track and log access to ePHI, enabling timely detection and response to any unauthorized activities. Ongoing security awareness training programs for personnel within the clearinghouse, emphasizing the importance of protecting ePHI and recognizing potential security risks.

Priority: High

Category: ePHI Protection and Access Control

Services Associated with AWS:

- N/A (This requirement is typically not specific to cloud services and focuses on internal policies and procedures.)

Services Associated with Azure:

- N/A (This requirement is typically not specific to cloud services and may apply to internal workforce management systems)

Objective Evidence:

- Administrative: Documented policies and procedures for protecting ePHI from unauthorized access.

- Technical: Records of access controls, encryption measures, and audit logs related to ePHI.

- Training Records: Documentation of security awareness training for clearinghouse personnel.

- Incident Response Documentation: Records of incident response procedures related to unauthorized access incidents.

Possible Technology Considerations:

- Access Control Systems

Encryption Solutions

- Audit and Monitoring Tools

- Security Awareness Platforms:

What Needs to Be Answered:

- How effective are access controls in preventing unauthorized access to ePHI within the clearinghouse?

- How quickly and effectively does the clearinghouse respond to incidents of unauthorized access to ePHI?

- To what extent do encryption measures protect ePHI from unauthorized access during transmission and storage?

- How impactful is the security awareness training program in fostering a culture of ePHI protection within the clearinghouse?

- To what extent do personnel within the clearinghouse adhere to established policies for protecting ePHI from unauthorized access?