CSF Assurance Program FAQs
How can I confirm an organizations certification status?
If you are in possession of a HITRUST report or letter PDF and are seeking verification that the PDF is authentic please contact firstname.lastname@example.org. You will be asked to provide a copy of the PDF in question and evidence showing you received it from the organization.
How can my organization utilize the CSF framework for an AICPA SOC 2 report?
HITRUST and AICPA collaborated on the mapping of HITRUST CSF controls to AICPA Trust Principles and Criteria for Security, Confidentiality, and Availability. Subsequently, any AICPA firm can perform a SOC 2 examination leveraging the CSF framework. This allows the client to receive in a combined format HITRUST Certification and a SOC 2 report. The next collaborative effort will be mapping the HITRUST CSF to the privacy principle.
What is the process for an organization to achieve HITRUST CSF Certification?
Before starting the Certification process, HITRUST recommends a self-assessment or readiness assessment be performed to prepare organizations for the validated assessment. To begin the Certification process, please select a HITRUST Assessor. Once you select an Assessor, you will need to purchase a validated assessment from HITRUST. Complete the validated assessment using the MyCSF tool and then the Assessor will perform the validation/audit work. Please note access to the MyCSF is granted for 90 days. Once the Assessor work is complete, please submit to HITRUST for review. HITRUST will create a report and, depending on the scores in the report, will issue a letter of certification.
Reference: CSF Assurance Program Requirements
How many organizations have completed a HITRUST CSF Assessment?
38,000 CSF Assessments have been performed in the last three years with 15,000 CSF Assessments in 2015 alone. HITRUST anticipates a continued demand for CSF Certification due to third-party assurance requirements from several major health organizations and requests for combined SOC 2 + HITRUST reports.
For more information, refer to the HITRUST Key Programs and Services overview.
If I’m HITRUST CSF Certified, does that mean I’m HIPAA compliant?
In principle yes, but it is not black and white. To be HIPAA-compliant, an organization must conduct a risk analysis and implement a reasonable and appropriate set of information safeguards—aka information security controls—to provide for the adequate protection of ePHI against all reasonably anticipated threats. In practice, organizations that want to demonstrate HIPAA compliance must generally show that it has addressed each standard and implementation specification in the Security Rule, including risk analysis. Organizations must therefore design or select multiple information security controls to provide the level of prescription necessary for implementation in the system or within the organization.
HITRUST helps organizations select these controls via its extensive mapping of the CSF controls to the HIPAA Security Rule’s standards and implementation specifications. Many of the HIPAA requirements are mapped to multiple controls, and the CSF controls themselves consist of multiple, specific protection requirements contained in multiple levels. By implementing the HITRUST CSF control requirements that are applicable to an organization based on its specific organizational, system and regulatory risk factors, each and every standard and implementation specification in the Security Rule is addressed in a very complete and robust way.
However, CSF certification is based on an assessment of a subset of the controls an organization is expected to implement. These controls were selected based on an analysis of past breach data and the need to address each and every standard and implementation specification in the HIPAA Security Rule. NIST supports the use of such targeted assessments to answer specific questions like this, and the use of a targeted assessment for CSF certification ensures relying organizations receive reasonable assurances at a reasonable cost.
DHHS specifically references HITRUST and the CSF with respect to risk management and risk assessment in its Guidance on Risk Analysis Requirements under the HIPAA Security Rule, and OCR has stated entities with a strong compliance program in place, with the help of a credentialing/accreditation program or on its own, would have that taken into account when determining past compliance. Implementation of the CSF as the basis for an organization’s information protection program and subsequent use of CSF validated or certified assessments has been previously accepted by OCR as evidence of its compliance with the HIPAA Security Rule, assuming the assessment addresses the appropriate scope relevant to OCR’s audit or investigation. The CSF and CSF Assurance Program has also been used in past resolution agreements with OCR.
What is the HITRUST QA Process?
The only change to the QA process is that the process will be performed in MyCSF. There are other changes that are being implemented to the QA process that are focused on ensuring the integrity and consistency of the assurance program. These changes will be announced as they are implemented.
Who will accept HITRUST CSF Assurance Reports?
Many organizations accept CSF Assurance reports as a means of evaluating a business partner’s privacy and security controls and in fact a growing number of organizations require their business partners obtain a CSF Certification..
Reference: HITRUST CSF Assurance Program Brochure
What is the length of time it takes to become HITRUST CSF Certified?
CSF Certification can be achieved when the minimum compliance level (a score of 3+ or 3 with corrective action plans) is met for all 75 CSF controls required for certification (2019 CSF v9.2 requirement). The total amount of time it can take an organization to become certified is therefore dependent on its initial readiness level and the amount of remediation needed to fully implement all the requirements in scope for the assessment. Most organizations will perform at least one self-assessment to gauge their readiness for certification and, once an organization is comfortable that they will meet the certification requirements, they will hire a CSF assessor to perform a validated assessment. These independent assessments can take anywhere from 2-8 weeks on average depending on the size and complexity of the organization and the scoped environment, and it can take a minimum of 8 weeks for the validated assessment to be processed and certification awarded by HITRUST. In general, it can take up to 3-4 months to complete the assessment and obtain certification once an organization is ready.
Reference: HITRUST CSF Assurance Program Requirements
Is a HITRUST certification assessment more expensive than comparable assessments?
No, and this is a common misconception and in many cases the overall assessment costs associated with information security and privacy assessments are less than other 3rd party assessments. The alignment between the HITRUST CSF and CSF Assurance programs allows a single CSF Assessment report to support multiple objectives, such as a HIPAA risk assessment and an assessment against the NIST Cybersecurity Framework, and in addition the same report can be accepted by external parties (such as business partners, government agencies) reducing the costs associated with multiple assessments.
For a fair comparison, one should consider various factors such as:
- Scope of the Assessment: Are both assessments reviewing the same scope?
- Applicability of the Control Requirements to the Environment: Are the controls requirements applicable to the organization or scope of assessment? Are they prescriptive and do they take into account relevant risk factors?
- Audit Ability: Does the framework have audit procedures to ensure consistency of assessment?
- Level of Assurance: How well is the process to ensure the control requirements implemented?
- Caliber of Organization Performing Assessment: Is It being performed by a 3rd party? What are the qualifications of the firm performing the assessment?
What are the various types of CSF Assessments?
HITRUST offers two types of CSF Assessments: a self-assessment and a validated assessment.
Self-assessment allows organizations to self-assess using the standard methodology, requirements, and tools provided under the CSF Assurance Program. HITRUST will then perform limited validation on the results of the self-assessment to provide a limited level of assurance to the relying entity.
Validated assessment is conducted by a HITRUST Certified External Assessor. The CSF Assurance methodology is used and the controls are scored accordingly. Assessments meeting or exceeding the current CSF Assurance scoring requirements for certification will be indicated as CSF Certified on the certification report.
What is the HITRUST CSF Assurance Program?
The HITRUST CSF Assurance program is a common, standardized methodology to effectively and consistently measure compliance and risk via simplified information collection and reporting, consistent testing procedures and scoring, and demonstrable efficiencies and cost-containment; and additional assurances around the accuracy, consistency and repeatability of assessments due to the use of pre-qualified professional services firms—all of which is designed to meet the unique regulatory and business needs of the healthcare industry. In short, it is a risk-based approach to selecting HITRUST CSF controls for assessment, including management oversight of the assessment. The HITRUST CSF Assurance Program delivers simplified compliance assessment and reporting that addresses multiple federal, state and industry requirements for both covered entities and their business associates.