Four-days comprehensive HIPAA Privacy and Security Certification Training for CHPSE (Level 1 & 2)

1. HIPAA Basics: An overview of the Health Insurance Portability and Accountability Act of 1996 (all provisions)
2. HIPAA’s Administrative Simplification Title: Review of the provisions of the Administrative Simplification Title. This includes transaction and code set standards (administrative transactions), national identifiers, privacy requirements, and security requirements.
3. HIPAA Penalties: Review of the HIPAA enforcement rule including informal and formal remedies, requirements of covered entities, the role of business associates as agents, and enforcement bodies.
4. HIPAA-Related Organizations: Discussion of entities/organizations specifically designated as standard maintenance organizations and statutorily defined advisory bodies.
5. HIPAA Terminology and Definitions Covered Entity: Review of definitions included in the
   Administrative Simplification Title-related rules (list not inclusive).

1. Transactions
2. Impacted Health Care Transactions
3. Target Entities
4. Scope
5. Penalties
6. ASCA

1. Transaction Type 270
2. Transaction Type 271
3. Transaction Type 276
4. Transaction Type 277
5. Transaction Type 278 Request and Response
6. Transaction Type 820
7. Transaction Type 834
8. Transaction Type 835
9. Transaction Type 837 – Professional
10. Transaction Type 837 – Institute
11. Transaction Type 837 – Dental

1. ICD-9-CM Volumes 1 and 2
2. CPT-4
3. CDT
4. ICD-9-CM Volume 3
5. NDC
6. HCPC

1. Provider Identifier
2. Employer Identifier
3. Health Plan Identifier
4. Individual Identifier

HIPAA Compliance Training – Day 2 Privacy

1. Introduction: Overview of the HIPAA Privacy Rule
   1. Who is Impacted (e.g., the definition of covered entities, business associates)?
   2. Scope (Activities covered by the rule)
   3. Exceptions (Specifically included or referenced exceptions that allow the use and disclosure of patient/health plan member protected health information (PHI))
   4. Timeline (Effective date of the rule, timelines related to certain requirements identified in the privacy rule such as accounting of disclosures, document retention requirements, etc.)
2. Key Definitions: Review of key definitions associated with the privacy rule and how they apply to rule application and compliance.
   1. IIHI
   2. PHI
   3. Deidentified Information
   4. Use
   5. Disclosure
   6. Treatment
   7. Payment
   8. Health Care Operations
3. Notice Requirement: Review of the requirements to draft and make available a notice of privacy practices, the content of the such notice, revision requirements, and availability requirements.
   1. Core Elements
   2. Changes to a Notice
   3. First Interaction
4. Authorization versus Consent Requirement: Review the legal definitions of consent and authorization and what they would be used for. Review of the legal requirements related to obtaining authorization, the form of such authorization, and content requirements.
   1. Definition of “consent”
   2. Definition of “authorization”
   3. Legal differences between “consent” and “authorization”
   4. Core Data Elements and Required Statements
   5. Defective Authorizations
   6. Revocations
5. Key Parties Impacted: A discussion of all entities or individuals directly or indirectly impacted by the rule and why.
6. Minimum Necessary: Discussion of the definition of the minimum necessary and when it applies to the use and disclosure of PHI (internally and externally)
7. Oral and Other Non-electronic Communications: A discussion of what constitutes PHI pursuant to the rule and the related requirements to protect non-electronic PHI, including oral PHI.
8. Health-Related Communications, Fund Raising, and Marketing: Review of the requirements related to the use of PHI for communications other than treatment, payment, and health care operations. Also, a review of the strict requirements relating to the use of PHI for marketing and fundraising.
9. Research: A review of the requirements related to the use of PHI for research including what processes must be followed prior to allowing the use of PHI in research without the patient/health plan member’s authorization.

1. Policy & Training Requirements: A review of the implied and explicit requirements to develop, implement and maintain privacy policies and procedures and the requirement to provide initial and ongoing staff training.
2. Preemption Requirements: A review of state law preemption. This includes a discussion regarding when state law may preempt the rule without specific authorization from the US Department of Health and Human Services (HHS) and when authorization is required prior to state law preemption of HIPAA.
3. State Privacy Laws: A general review of state privacy laws that preempt HIPAA (categorized as specially protected health information) with specific reference to select California state laws.
4. Federal Privacy Law – 42 CFR Pt. 2: A discussion of the most stringent requirements found in 42 CFR Pt. 2 relating to alcohol and chemical dependency
5. Statutory/Rule Conflict Resolution: Discussion of how to respond when federal and/or state law conflicts.
6. Case Law: A review of general case law that has impacted the application of HIPAA, state privacy laws, and impacts legal risks.

HIPAA Compliance Training – Day 3 Security

1. General:
2. Threats: General review of threats (real and perceived) prompting Congress to include security requirements in the HIPAA Administrative Simplification Title.
3. Definition and Terminology: Review of general definitions of security and specifically how those definitions apply to the rule and what data must be protected by the implementation of appropriate security measures.
   1. Security
   2. Security Services
   3. Security Mechanisms
   1. General (continued):
   2. Security Rules: Detailed review of the security rule, components of the security rule, and specific requirements (including a reference back to security requirements referenced in the HIPAA Privacy Rule).
   1. Categories of Safeguards
   2. Implementation Specifications
   3. Approach and Philosophy
   4. Security Principles
   1. Administrative Safeguards
   2. Physical Safeguards
   3. Technical Safeguards
   4. Organizational Requirements
   5. Policies and Procedures, and Documentation Standards
   6. Administrative Safeguards: Definition of “administrative safeguards” as they relate to security and the rule. A review of required administrative safeguards and their application within a covered entity and business associate.
   7. Administrative Safeguards
   8. Security Management Process
   9. Assigned Security Responsibility
   10. Workforce Security
   11. Information Access Management
   12. Security Awareness and Training
   13. Security Incident Procedures
   14. Contingency Plan
   15. Evaluation
   16. Business Associate Contracts Standard
   1. Physical Safeguards: Definition of “physical safeguards” as they relate to security and the rule. A review of required physical safeguards and their application within a covered entity and business associate.
   2. Requirements
   3. Facility Access Controls
   4. Workstation Use
   5. Workstation Security
   6. Device and Media Controls
   7. Physical Safeguards Review

1. Technical Safeguards (general): Definition of “technical safeguards” as they relate to security and the rule. A review of required technical safeguards and their application within a covered entity and business associate.
2. Requirements
3. Access Control
4. Audit Controls
5. Integrity
6. Person or Entity Authentication
7. Security Compliance process: Risk Analysis, Vulnerability Assessment, Remediation, Contingency Planning, Audit & Evaluation
8. Transmission Security
9. Technical Safeguards (technical details): A review of required technical safeguards including a more technical review of required or addressable safeguards, implementation, and ongoing maintenance.
10. TCP/IP Network Infrastructure
11. Firewall Systems
12. Virtual Private Networks (VPNs)
13. Wireless Transmission Security
14. Encryption
15. Overview of Windows XP and Vista Security

HIPAA Compliance Training – Day 4 Security, Enforcement Rule & ARRA 2009

1. Digital Signatures & Certificates: A review of the use of higher forms of individual or entity authentication that is quickly becoming a requirement legally and to reduce legal risk.
2. Requirements
3. Digital Signatures
4. Digital Certificates
5. Public Key Infrastructure (PKI)
6. Solution Alternatives
7. Identity theft prevention and HIPAA
8. Security Policy: A review of the requirements to document security program practices and processes in policy and related workforce training requirements. Also a review of required policy maintenance and retention.
9. Risks, Risk Management, and Policy Development/Implementation
10. General Security Standards Impact on Policy Development
11. Policy Training Requirements
12. Security Policy Considerations

1. Overview: An overview of the rule and rule requirements including entities and individuals the rule applies to
2. Definitions: A review of rule definitions including (not inclusive) what represents a violation, compliance, definition of agent, resolution processes, and HHS enforcement powers.
3. Informal resolution process: A discussion of what an informal resolution is and what it entails. Also, a review of the rule’s emphasis on informal resolution and language allowing such resolution at any phase of a violation investigation, penalty assessment, and appeal.
4. Formal resolution process (i.e., penalties, administrative hearings, appeal process, etc.): A discussion of what would likely trigger a formal resolution process, HHS requirements and authority to investigate, rights and responsibilities of covered entities and resulting actions if civil penalties are levied and paid by the covered entity.
5. Compliance audits A discussion of the authority to conduct compliance audits, current audit activity, and prospective audit activity.

1. Privacy Provision Overview: Overview of the privacy provisions included ARRA and the relationship to the HIPAA Administrative Simplification Title provisions.

1. Business Associates – New Requirements: A discussion of business associates’ new requirement to statutorily adhere to the provisions of the HIPAA Administrative Simplification Title Privacy and Security Rules. The discussion includes a review of the timeline for compliance and the implications for business associates.
2. National Identity Theft Protection Provisions: A discussion of the requirements of the new identity theft protection provisions, what is considered a breach or inappropriate disclosure, breach notification requirements, and entities/individuals covered. The discussion also includes new reporting requirements by entity/individual, HHS, and the Federal Trade Commission (FTC).
3. Marketing Prohibitions and Restrictions: An overview of the enhanced restrictions related to the use and disclosure of PHI where the entity or individual is paid for such use and disclosure and stricter prohibitions against using PHI for marketing purposes.
4. Enforcement Provisions: A discussion of the new enforcement provisions, entities/individuals covered, and how such enforcement relates to the HIPAA Enforcement Rule and current compliance audits. The discussion also includes a discussion of changes in penalties and the addition of a newly defined criminal act (formerly a civil violation).
5. Reporting Requirements: A discussion of new requirements for the reporting of breaches to HHS and/or the FTC and annual reports relating to compliance, rule violations, breaches, etc. to Congress and the public.

1. Red Flag Rule Overview
2. Definition of “red flags” and how to spot them
3. State Identity Theft Protection Laws & ARRA Breach Notification Requirements
4. Identity Theft Protection Program Requirements
5. Implementation Tips

1. ARRA & Meaningful Use Rule Overview
2. Meaningful Use Requirements – Stage 1 & 2
3. Privacy & Security Related Measures
4. Meeting Core Requirement 15 (HIPAA Compliance)
5. Vendor Requirements
6. How to Prepare

1. Background
2. Breach Notification Rule
3. New Limits on Uses and Disclosures of PHI
4. Business Associates
5. Increased Patient Rights
6. Notice of Privacy Practices
7. Increased Enforcement

HIPAA Compliance Training – Day 5 (part of onsite training/customized HIPAA training only)

• HIPAA Compliance Training Manual (worth $450)
• HIPAA Security Policy Templates (sent by e-mail) (worth $495)

• Certified HIPAA Privacy Security Expert (CHPSE)
• Certified HIPAA Security Expert (CHSE)
• Certified HIPAA Privacy Expert (CHPE)
• Certified HIPAA Privacy Associate (CHPA)