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Security Management Process. A covered entity must identify and analyze potential risks to ePHI, and it must implement security measures that reduce risks and vulnerabilities to a reasonable and appropriate level.

Security Personnel. A covered entity must designate a security official who is responsible for developing and implementing its security policies and procedures.

Information Access Management. The Security Rule requires a covered entity to implement policies and procedures for authorizing access to ePHI only when such access is appropriate based on the user or recipient’s role (role-based access).

Workforce Training and Management. A covered entity must provide for appropriate authorization and supervision of workforce members who work with ePHI. A covered entity must train all workforce members regarding its security policies and procedures, and must have and apply appropriate sanctions against workforce members who violate its policies and procedures.

Evaluation. A covered entity must perform a periodic assessment of how well its security policies and procedures meet the requirements of the Security Rule.

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The Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting ePHI.

HHS recognizes that covered entities range from the smallest provider to the largest, so the Security Rule is flexible and scalable to allow covered entities to analyze their own needs for compliance policies and procedures, and implement solutions appropriate for their specific environments.
When a covered entity is deciding which security measures to use, the Rule does not dictate those measures but requires the covered entity to consider:

Its size, complexity, and capabilities,

Its technical, hardware, and software infrastructure,

The costs of security measures, and

The likelihood and possible impact of potential risks to ePHI.

Covered entities must review and modify their security policies to continue protecting ePHI in their ever changing environment.

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HIPAA Policies and Procedures for Business Associates and Contracts

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HIPAA Policies and Procedures for Business Associates and Contracts

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A business associate is a person or organization, other than a member of a covered entity’s workforce, that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing. Business associate services to a covered entity are limited to legal, actuarial, accounting, consultant, data aggregation, management, administrative, accreditation, or financial services. However, persons or organizations are not considered business associates if their functions or services do not involve the use or disclosure of protected health information, and where any access to protected health information by such persons would be incidental, if at all. A covered entity can be the business associate of another covered entity.

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The Privacy Rule addresses the use and disclosure of individuals’ health information called “Protected Health Information (PHI).”  These types of organizations are called “covered entities.”  The Privacy Rule standards outline for covered entities individuals’ privacy rights to understand and control how their health information is used.  HHS and the Office for Civil Rights (OCR) have the responsibility for implementing and enforcing the Privacy Rule with respect to compliance activities and civil money penalties. The Privacy Rule is to assure that an individuals’ health information is properly protected while allowing the individuals’ necessary health information that is needed to provide and promote quality health care, is protected. The Privacy Rule permits important uses of information, while protecting the privacy of people who seek healthcare.

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HIPAA Security Policies and Procedures for Health Care Providers

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HIPAA Security Policies and Procedures for Health Care Providers

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Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transactions Rule. Using electronic technology, such as email, does not mean a healthcare provider is a covered entity; the transmission must be in connection with a standard transaction.
The Privacy Rule covers a healthcare provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf.

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HIPAA Policies and Procedures and Documentation Requirements

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HIPAA Policies and Procedures and Documentation Requirements

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A covered entity must adopt reasonable and appropriate policies and procedures to comply with the provisions of the Security Rule. A covered entity must maintain, until six years after the later of the date of their creation or last effective date, written security policies and procedures and written records of required actions, activities or assessments.

Updates. A covered entity must periodically review and update its documentation in response to environmental or organizational changes that affect the security of electronic protected health information (ePHI).