Contingency Plan: Disaster Recovery Plan-What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the second implementation specification for the Administrative Safeguard Standard (Contingency Plan). This implementation specification is required. As HIPAA.com has noted in earlier postings, with enactment of the American Recovery and Reinvestment Act of 2009 (ARRA) on February 17, 2009, business associates also will be required to comply with the Security Rule standards, effective February 17, 2010. What to Do Establish (and implement as needed) procedures to restore any loss of data. How to Do It The content and procedures of a covered entity’s disaster recovery plan will be » Outcomes of the covered entity’s identification of vulnerabilities and…

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Security Incident Procedures Response and Reporting: What to Do and How to Do It

This is the sixth Administrative Safeguard Standard of the HIPAA Administrative Simplification Security Rule. This is its one implementation specification, Response and Reporting, which is required for compliance. As we have noted in earlier postings, with enactment of the American Recovery and Reinvestment Act of 2009 (“ARRA”) on February 17, 2009, business associates also will be required to comply with the Security Rule standards, effective February 17, 2010. What to Do This standard requires that the covered entity implement response and reporting policies to address security incidents. A security incident is defined as “the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system…

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Security Incident Procedures: What This HIPAA Security Rule Administrative Safeguard Standard Means

This is the sixth Administrative Safeguard Standard of the HIPAA Administrative Simplification Security Rule. It has one implementation specification:  Response and Reporting, which is required for compliance. As we have noted in earlier postings, with enactment of the American Recovery and Reinvestment Act of 2009 (“ARRA”) on February 17, 2009, business associates also will be required to comply with the Security Rule standards, effective February 17, 2010. This safeguard standard and its implementation specification require covered entities to establish policies and procedures to respond to security incidents and to report them. A security incident is defined as “the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information…

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Information Access Management: Access Establishment and Modification-What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the third implementation specification for the Administrative Safeguard Standard (Information Access Management). This implementation specification is addressable. Remember, addressable does not mean “optional.”  Rather, an addressable implementation specification means that a covered entity must use reasonable and appropriate measures to meet the standard. Further, as we have noted in a posting last week, with enactment of the American Recovery and Reinvestment Act of 2009 on February 17, 2009, business associates also will be required to comply with the Security Rule standards, effective February 17, 2010. What to Do Implement policies and procedures that, based upon the covered entity’s…

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Effective Dates for Modified HIPAA Administrative Simplification Transaction and Code Set Rules Coming in March

In less than three weeks, HIPAA Version 5010/D.0 transaction and ICD-10 code set rules become effective, and the clock starts running on testing in preparation for compliance several years hence. Next Monday, March 2, 2009, HIPAA.com will outline Level 1 testing requirements and opportunities for the 5010/D.0 transaction rule, and on Tuesday, March 3, 2009, outline testing requirements for ICD-10. Sign up for HIPAA.com email reminders for these and other HIPAA Administrative Simplification standards postings, as well as postings relating to the new Health Information Technology for Economic and Clinical Health Act and Medicare and Medicaid Health Information Technology (“HITECH Act”) provisions of the American Recovery and Reinvestment Act (“ARRA”)…

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Information Access Management: Access Authorization-What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the second implementation specification for the Administrative Safeguard Standard (Information Access Management). This implementation specification is addressable.  Remember, addressable does not mean “optional.”  Rather, an addressable implementation specification means that a covered entity must use reasonable and appropriate measures to meet the standard.  Further, as we have noted in a posting last week, with enactment of the American Recovery and Reinvestment Act of 2009 on February 17, 2009, business associates also will be required to comply with the Security Rule standards, effective February 17, 2010. What to Do Implement policies and procedures for granting access to electronic protected…

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Information Access Management: Isolating Healthcare Clearinghouse Functions-What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the first implementation specification for the Administrative Safeguard Standard (Information Access Management). This implementation specification is required. What to Do If a healthcare clearinghouse is part of a larger organization, the clearinghouse must implement policies and procedures that protect the electronic protected health information of the clearinghouse from unauthorized access by the larger organization. Remember, a clearinghouse is defined as a covered entity, but also can serve in the role of a business associate to other covered entities, namely a health plan or healthcare provider. How to Do It This implementation specification is required, but is not likely…

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Information Access Management-What This HIPAA Security Rule Administrative Safeguard Standard Means

This is the fourth Administrative Safeguard Standard of the HIPAA Administrative Simplification Security Rule. It has three implementation specifications: Isolating Healthcare Clearinghouse Functions; Access Authorization; and Access Establishment and Modification. The first is required; the second and third are addressable. Addressable does not mean “optional.” Rather, an addressable implementation specification means that a covered entity must use reasonable and appropriate measures to meet the standard. Further, as we noted in a posting last week, with enactment of the American Recovery and Reinvestment Act of 2009 on February 17, 2009, business associates also will be required to comply with the Security Rule standards, effective February 17, 2010. The covered entity is…

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Security Management Process: Information System Activity Review-What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the fourth implementation specification for the Administrative Safeguard Standard (Security Management Process). This implementation specification is required. What to Do Implement procedures to regularly review records of information of system activity, such as audit logs, access reports, and security incident tracking reports. How to Do It Size of the covered entity and complexity of the business operation will be key considerations in the risk analysis and in fulfilling the requirements of this implementation specification. First, regularly review information system activity for inappropriate use or security incidents, such as unauthorized disclosure. Many computer systems now have built-in reporting functionality…

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Security Management Process: Sanction Policy-What to Do and How to Do It

In our series on the HIPAA Administrative Simplification Security Rule, this is the third implementation specification for the Administrative Safeguard Standard (Security Management Process). This implementation specification is required. What to Do Apply appropriate sanctions against workforce members who fail to comply with the security policies and procedures of the covered entity. How to Do It The covered entity must determine appropriate internal sanctions or penalties for violation of its security policies and procedures by workforce members. Sanctions should: » Deter noncompliant behavior, such as posting passwords on computer hardware or under a desk pad. » Serve as an incentive for compliance with security policies and procedures. The appropriate sanctions…

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