HIPAA · Control 164.402(b) · Priority: medium · Component: Breach Notification Rule

What this control covers

Definitions: Breach Exceptions - Unsecured PHI Breach means the acquisition, access, use, or disclosure of PHI in a manner not permitted under subpart E of this part which compromises the security or privacy of the PHI. (1) Breach excludes: (i) Any unintentional acquisition, access, or use of PHI by a workforce member or person acting under the authority of a covered entity or a business associate, if such acquisition, access, or use was made in good faith and within the scope of authority and does not result in further use or disclosure in a manner not permitted under subpart E of this part. (ii) Any inadvertent disclosure by a person who is authorized to access PHI at a covered entity or business associate to another person authorized to access PHI at the same covered entity or business associate, or organized health care arrangement in which the covered entity participates, and the information received as a result of such disclosure is not further used or disclosed in a manner not permitted under subpart E of this part. (iii) A disclosure of PHI where a covered entity or business associate has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information. (2) Except as provided in paragraph (1) of this definition, an acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E is presumed to be a breach unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the protected health information has been compromised based on a risk assessment of at least the following factors: (i) The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification; (ii) The unauthorized person who used the protected health information or to whom the disclosure was made; (iii) Whether the protected health information was actually acquired or viewed; and (iv) The extent to which the risk to the protected health information has been mitigated. Unsecured protected health information means protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the Secretary in the guidance issued under section 13402(h)(2) of Public Law 111-5.

Why it matters

Risk is the language an executive team understands; this control connects technical reality to board-level decisions and budget allocation.

How to implement

AWS

Codify the policy intent as SCPs, AWS Config conformance packs, and Security Hub standards so the cloud enforces what the document says.

Azure

Codify in Azure Policy initiatives (built-in regulatory compliance for CIS, ISO 27001, SOC 2, HIPAA) and assign at management-group level.

On-premises

Maintain a policy library with a documented review cadence (annual minimum); store in your GRC tool with attestation tracking. Map each policy to controls so an audit pull cites the exact policy clause.

Evidence to collect

  • policy_document — A signed, version-controlled policy stating leadership intent and the named owner.

Signed policy or standard documents the safeguard. Focus: Definitions: Breach - exceptions (unsecured PHI).

Quick checklist

  • Security — Security / Management
  • Workforce — Security / Management
  • Information — Security / Management
  • Business — Security / Management
  • Person — Security / Management
  • Policy — Security / Management

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