Information Access Management
164.308(a)(3)
Administrative Safeguards
High Risk
Complex
Implement policies and procedures for authorizing access to ePHI that are consistent with the applicable requirements of the Security Rule.
Implementation Guidance
Develop comprehensive information access management policies including:
• Access authorization procedures
• Access establishment and modification procedures
• Access review and recertification processes
• Emergency access procedures
• Access termination procedures
• Documentation of access decisions
Key requirements:
- Isolating healthcare clearinghouse functions
- Access authorization based on job functions
- Regular access reviews and updates
- Emergency access procedures
- Proper documentation of all access decisions
• Access authorization procedures
• Access establishment and modification procedures
• Access review and recertification processes
• Emergency access procedures
• Access termination procedures
• Documentation of access decisions
Key requirements:
- Isolating healthcare clearinghouse functions
- Access authorization based on job functions
- Regular access reviews and updates
- Emergency access procedures
- Proper documentation of all access decisions
NIST References
NIST SP 800-66 Rev. 2: Section 3.1.3
NIST Cybersecurity Framework: PR.AC-1, PR.AC-2, PR.AC-3, PR.AC-4, PR.AC-5, PR.AC-6, PR.AC-7
NIST SP 800-53: AC-1, AC-2, AC-3, AC-4, AC-5, AC-6, AC-7, AC-8, AC-9, AC-10, AC-11, AC-12, AC-13, AC-14, AC-15, AC-16, AC-17, AC-18, AC-19, AC-20, AC-21, AC-22
NIST Cybersecurity Framework: PR.AC-1, PR.AC-2, PR.AC-3, PR.AC-4, PR.AC-5, PR.AC-6, PR.AC-7
NIST SP 800-53: AC-1, AC-2, AC-3, AC-4, AC-5, AC-6, AC-7, AC-8, AC-9, AC-10, AC-11, AC-12, AC-13, AC-14, AC-15, AC-16, AC-17, AC-18, AC-19, AC-20, AC-21, AC-22
Best Practices
• Implement role-based access control (RBAC)
• Regular access reviews and recertification
• Document all access decisions and rationale
• Implement emergency access procedures
• Use automated access management tools
• Regular training on access management
• Monitor and audit access regularly
• Regular access reviews and recertification
• Document all access decisions and rationale
• Implement emergency access procedures
• Use automated access management tools
• Regular training on access management
• Monitor and audit access regularly
Testing Procedures
• Review access management policies and procedures
• Test access authorization processes
• Verify access review and recertification procedures
• Test emergency access procedures
• Review access termination procedures
• Verify documentation of access decisions
• Test monitoring and auditing capabilities
• Test access authorization processes
• Verify access review and recertification procedures
• Test emergency access procedures
• Review access termination procedures
• Verify documentation of access decisions
• Test monitoring and auditing capabilities
Frequently Asked Questions
Q: What is the difference between access authorization and access establishment?
A: Access authorization is the process of determining what access a user should have, while access establishment is the technical implementation of that access.
Q: How often should access be reviewed?
A: Access should be reviewed at least annually, or more frequently for high-risk positions or when job functions change.
Q: What should be included in emergency access procedures?
A: Emergency access procedures should include criteria for when emergency access is needed, who can authorize it, how it is implemented, and how it is monitored and terminated.
A: Access authorization is the process of determining what access a user should have, while access establishment is the technical implementation of that access.
Q: How often should access be reviewed?
A: Access should be reviewed at least annually, or more frequently for high-risk positions or when job functions change.
Q: What should be included in emergency access procedures?
A: Emergency access procedures should include criteria for when emergency access is needed, who can authorize it, how it is implemented, and how it is monitored and terminated.
Control Information
Control ID:
164.308(a)(3)
164.308(a)(3)
Category:
Administrative Safeguards
Administrative Safeguards
Subcategory:
Security Management Process
Security Management Process
Risk Level:
High
High
Implementation Difficulty:
Complex
Complex
Estimated Cost:
High
High
Implementation Timeframe:
3-6 months
3-6 months
Views:
3
3
Last Updated:
Oct 1, 2025
Oct 1, 2025
Related Controls
Additional Resources
• NIST SP 800-66 Rev. 2: Information Access Management Guidance
• HHS Information Access Management Guidance
• Role-Based Access Control Implementation Guide
• Access Management Best Practices
• Emergency Access Procedures Template
• HHS Information Access Management Guidance
• Role-Based Access Control Implementation Guide
• Access Management Best Practices
• Emergency Access Procedures Template