HITRUST

What’s the difference between HITRUST CSF and HIPAA?

HITRUST CSF and HIPAA assessments both aim to safeguard healthcare information and electronic Protected Health Information EPHI. However, both standards offer a different approach for organizations.

HIPAA was originally meant to be utilized for a wide range of organizations, resulting in a vague and subjective list of requirements to be HIPAA compliant. The HIPAA Security Rule allows for certain specifications to be only “addressable” while others are “required.” There is no official designation of HIPAA compliance.

HITRUST CSF assessments and certifications are organized around the specific risk of a certain organization. HITRUST CSF assessments also allow for a comprehensive approach toward information security as it considers compliance with other regulations. A HITRUST CSF assessment is an efficient and risk-based approach to information security because it draws upon existing frameworks, standards, and current regulations.

What is the HITRUST CSF Certification process like?

I.S. Partners, LLC will perform a HITRUST CSF readiness, certification, and remediation services for healthcare organizations and their business associates to assess compliance with industry security requirements and standards, and create solutions that help organizations align with the HITRUST CSF. If your company requires both a HITRUST CSF Certification and a SOC 2 report, I.S. Partners can leverage the efficiencies between both sets of requirements, thus lowering the time and expense of effective risk management.

Is the HITRUST CSF similar to SOC report requirements?

A SOC 2 is a reporting format, while the HITRUST CSF is a security framework. A SOC 2 examination examines the internal controls at a service organization as they relate to one or more of the Trust Services Principles of Security, Availability, Confidentiality, Processing Integrity and Privacy. The SOC 2 reporting model and the HITRUST security framework are complementary since both are facilitated through the efficient assessment and implementation of controls to satisfy the HITRUST CSF.

What is the advantage of getting HITRUST CSF certified?

An organization that creates, accesses, stores or exchanges Protected Health Information (“PHI”) can use its HITRUST CSF Certification to demonstrate that they meet the high standards of security prescribed within the HITRUST CSF. Many companies now accept a HITRUST Certification as evidence of compliance, thus relieving them of the obligation to audit their vendors. Companies such as Highmark, Humana, United Health Group, HCSC and Anthem now require their vendors to undergo a HITRUST CSF assessment. The HITRUST CSF incorporates all major information security-related requirements and best practices, and provides scalable cyber security measures based on different risks and exposures.

Who is HITRUST

HITRUST is a privately held corporation in the United States that has established the HITRUST CSF to be used by organizations that create, access, store or exchange sensitive information. In collaboration with public and private healthcare technology, privacy and information security leaders, HITRUST has become the leader in safeguarding health information systems and exchanges.

What are the Two Different Types of HITRUST CSF Assessments that HITRUST Offers?

1. A HITRUST CSF Self-Assessment allows an organization to conduct a review and assessment of its internal control environment using the standard methodology, requirements, and tools provided under the HITRUST CSF Assurance Program. The self-assessment option removes any potential barriers for organizations that lack the resources for an onsite assessment, but nonetheless must still implement data protection controls, maintain HIPAA/HITECH compliance, and report to external parties.

2. A HITRUST Validated Assessment is conducted by a HITRUST approved CSF Assessor, such as I.S. Partners, LLC. Using the HITRUST CSF Assurance methodology, an organization’s internal controls are scored accordingly. Assessments meeting or exceeding the current HITRUST CSF Assurance scoring requirements for certification will be indicated as “HITRUST CSF Certified” on the certification report from HITRUST.

Why Should You Choose the HITRUST CSF Over Other Available Frameworks (NIST, ISO, etc.)?

The HITRUST CSF includes and embodies requirements from various authoritative sources such as ISO, NIST, PCI DSS, HIPAA and others, and tailors the requirements to healthcare organizations based on specific organizational, system and regulatory risk factors. The level of integration and prescription in the framework, along with the quality and rigor of the HITRUST CSF Assurance Program and supporting HITRUST products and services, makes the HITRUST CSF the easy choice for healthcare organizations.

How Can My Organization Utilize the HITRUST CSF Framework for a SOC 2 Report?

HITRUST and the American Institute of Certified Public Accountants (AICPA) have joined together to map HITRUST CSF controls to the Service Organization Controls (SOC) 2 Trust Principles and Criteria, specifically the Trust Services Principles of Security, Confidentiality and Availability. I.S. Partners, LLC, as both a CPA firm and a HITRUST CSF Assessor, can perform a SOC 2 audit leveraging the HITRUST CSF framework. If an organization requires both a SOC 2 and a HITRUST CSF Certification report, the two reports can be combined into a singular report.

How Often Do I Need to Get a Report?

Given the positive fulfillment of the interim review requirement, where no breach has occurred and no significant changes have developed relating to the scoped control environment, HITRUST CSF reports with Certification are valid for two years. However, at the one-year anniversary of the Certification, I.S. Partners, LLC can perform your organization’s interim review by:

  • Requesting your organization to update the scoping questions
  • Reviewing the updated questionnaire for any changes to original questionnaire
  • Testing at least one control/statement in each domain
  • Reviewing the status of any Corrective Action Plan (CAP) from the original assessment to ensure that satisfactory progress/milestones are being met

PCI Audit

Can my business can stay PCI-DSS compliant if I use a single vendor and product, or if I outsource the card processing tasks?

No single vendor or product will cover all 12 PCI-DSS requirements or meet several minimal standards. Instead, you should create a comprehensive security strategy that reaches PCI compliance and then use products and vendors that further complement your network system security to provide enhanced protection.

If you decide to outsource your credit card transactions, you will still need to meet PCI-DSS compliance when transmitting cardholder data to the outsourced company. You also need to ensure that the outsourcing company you use meets PCI-DSS compliance.

Does PCI-DSS only apply to businesses that store credit card information?

Any business or merchant that accepts credit card payments, transmits cardholder data, processes transactions and/or stores cardholder information falls under PCI-DSS requirements.

Is PCI-DSS Voluntary?

No. Any business that engages in credit card transactions must follow PCI-DSS requirements to safeguard cardholder information

What are the PCI-DSS v3.2 standards?

There are 12 requirements for PCI-DSS v3.2 which are listed here.

What is the Prioritized Approach in PCI DSS?

The Prioritized Approach groups the 12 PCI-DSS standard requirements into 6 milestones to provide a roadmap in developing, implementing and monitoring security protocols and policies. It also helps assessors in evaluating security controls so there is more consistency in their auditing methods.

Read what the 6 milestones for PCI-DSS v3.2 are here.

What is PCI-DSS v3.2?

PCI-DSS v3.2 is the newest standard version that was introduced in 2016. It revised and changed several of the standard requirements that were a part of the original PCI-DSS.

Read more about the newest version of PCI-DSS (v3.2) here.

Are there penalties for PCI non-compliance?

Yes. Based on the discretion of the credit card company, acquiring banks can be fined from $5,000 up to $100,000 per month. Banks may pass off this fine to the business or merchant as well as increase transaction fees for the business or terminate their business relationship.

Are there compliance levels for PCI-DSS?

Yes. Compliance levels for PCI-DSS are based on the volume of credit card payment transactions that are made within a 12-month period. There are 4 merchant compliance levels defined by the Visa credit card brand .

Find out what the 4 levels of PCI-DSS compliance are here.

What is PCI-DSS?

Major credit card companies such as MasterCard, Visa, Discovery, American Express, and JCB International created the Payment Card Industry Security Standards Council (PCI SSC) to help companies globally with their security systems when transmitting, receiving, using and storing cardholder information.

Get the full answer here

What must penetration testing include?

A penetration test must include manual testing, performed by qualified individuals who can accurately emulate the activities of a malicious user attempting to compromise the cardholder environment.

What does the PCI DSS require?

The PCI DSS requires internal and external network penetration testing, as well as application-layer penetration testing, as a means to find exploitable vulnerabilities.

To whom does PCI apply?

PCI applies to ANY organization or merchant, regardless of size or number of transactions, that accepts, transmits or stores any cardholder data. Said another way, if any customer of that organization ever pays the merchant directly using a credit card or debit card, then the PCI DSS requirements apply.

SOC Audit

What is the difference between a Type I audit and a Type II audit?
A Type I audit results in a report on management’s description of the service organization’s system and the suitability of the design of the controls to achieve the related control objectives included in the description as of a specific date. A Type II audit is the same as a Type I audit but with a report on the operating effectiveness of the controls throughout a specified period.
Why is I.S. Partners qualified to perform SOC audits?
I.S. Partners, LLC is a Certified Public Accounting firm registered with the AICPA (American Institute of Certified Public Accountants) and PCAOB (Public Company Accounting Oversight Board), and is managed by a group of highly-seasoned partners who have vast experience in performing SAS 70 / SSAE 16 / SOC audits, FISMA, HIPAA HITECH, Sarbanes-Oxley (Section 404) management self-assessments, Model Audit Rule compliance, and other specialized information technology audits.

SSAE-18 Audit

How much does an SSAE-18 audit cost?
Fees are based on the time required by the auditors assigned to the engagement and take into account the agreed-upon level of preparation and assistance from the company’s personnel. Fees will vary based on the number of control objectives and control activities within a service organization, whether the audit is a Type I or Type II, and the number of locations included in the audit scope. Talk to an I.S. Partners representative to discuss the scope of your company’s SSAE 18 audit.
How long does it take to complete an SSAE-18 audit?
A Type I audit typically takes from 6 to 10 weeks, while a Type II audit typically takes from 12 to 14 weeks. Depending on the unique circumstances of each SSAE 18 audit, including the client resources assisting with the project, the amount of report preparation, and the quality review process, the actual completion time may be shorter or longer than anticipated.
What is the difference between SSAE-18 and SAS-70?
One primary change is that we, as your independent service auditor, will examine the procedures your organization follows to monitor the controls of your subservice providers, and how your organization assesses the risks that may be associated with your use of subservice providers.Additionally, under SSAE 18, a service organization’s controls are designed with the assumption that subservice organizations have implemented complementary subservice organization controls that are necessary to achieve the service organization’s control objectives.
Is SSAE-18 a certification?
No such certification exists. Officially, service organizations can only claim that they have been examined in accordance with SSAE 18 attestation standards and that the corresponding Service Organization Controls (SOC) 1 report should be read for further details. SOC 1 reports are “restricted use” reports intended only for existing customers and their auditors, and not for the general public.
What is SAS-70?
SAS-70 stands for “Statement on Auditing Standards No. 70”, and was the guidance established by the American Institute of Certified Public Accountants (AICPA) for reporting on controls at a service organization. This guidance was replaced by Statement on Standards for Attestation Engagements (SSAE) No. 16, effective on June 15, 2011.
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