What evidence do auditors commonly ask for on 164.314(b)(1) Requirements for Group Health Plans (Standard)?

Plan document amendments addressing ePHI safeguards; Plan sponsor security obligations documentation; Records of disclosures to plan sponsor; Determination of group health plan applicability; Procedures for limited disclosures under 164.504(f); Annual review of plan sponsor compliance.

What is the most common gap auditors find on 164.314(b)(1)?

Plan documents not updated to reflect ePHI safeguards

HIPAA Security Rule · Organizational

`164.314(b)(1)` Requirements for Group Health Plans (Standard)

Except when the only ePHI disclosed to a plan sponsor is disclosed pursuant to 164.504(f)(1)(ii) or (iii), or as authorized under 164.508, a group health plan must ensure that its plan documents provide that the plan sponsor will reasonably and appropriately safeguard ePHI created, received, maintained, or transmitted to or by the plan sponsor on behalf of the group health plan.

Source: HIPAA Security Rule, 164.314(b)(1). The statement above is our statement of the clause, read from the published text and cited so you can check it against the official text, not the instrument verbatim. Open HIPAA Security Rule in the compliance library.

Applies to covered entities and business associates. An addressable specification can be met by a documented, reasonable alternative.

artefacts

held by a system

at each review

hard

to go live

Policy repository / GRC workspace

where the evidence lives

teal = a system already holds it · olive = produced at each review. To go live: easy when half or more of the artefacts are already held by a system, moderate from a quarter to a half, hard below a quarter.

These are the artefacts auditors commonly ask for on this requirement, our guidance rather than text from the standard. Your assessor decides what is sufficient in your context, and asks for samples across the period when a report covers one.

system holds itEvidence a system already holds

none for this control

periodic reviewEvidence produced at each review

Records of disclosures to plan sponsor · Policy repository / GRC workspace
Annual review of plan sponsor compliance · Policy repository / GRC workspace
Plan sponsor workforce training records · HR system / LMS

governing documentDocuments that govern the control

Plan document amendments addressing ePHI safeguards · Policy repository / GRC workspace
Plan sponsor security obligations documentation · Policy repository / GRC workspace
Determination of group health plan applicability · Policy repository / GRC workspace
Procedures for limited disclosures under 164.504(f) · Policy repository / GRC workspace
Coordination procedures between plan and sponsor · Policy repository / GRC workspace

First move

No system holds this evidence for you: it is people and documents. Reminders and routing to the owner still save time. Put the document under version control with an owner and review date, and log each review as a record with reviewer and date.

Common gaps auditors find

Plan documents not updated to reflect ePHI safeguards
Plan sponsor practices not aligned to plan obligations
Disclosures exceed allowed scope
No applicability determination
Plan sponsor training absent
No annual compliance review

Do this for your whole sheet

Paste the rows you run your controls from and get this mapping for every control at once, with the periodic-review ones flagged and a first move per row. No account for the first run.

Build my evidence sheet

164.314(a)(2)(iii) Business Associate Contracts with Subcontractors · 164.314(b)(2) Implementation Specifications for Group Health Plans