HIPAA §164.308(a)(4) - Information Access Management

🔑 AUDIT-GRADE EVIDENCE • Follows AICPA SOC 2 / HHS HIPAA / PCI QSA ROC / NIST 800-53A • Report tamper-evident via SHA-256 chain

1. CONTROL IDENTIFICATION

FrameworkHIPAA Security Rule
Control ID§164.308(a)(4)
Control FamilyAdministrative Safeguards > Access Management
Control NameInformation Access Management
StatusPARTIALLY IMPLEMENTED
Assessment Date2026-04-19T02:25:35.202960+00:00
AssessorTITAN AI Scanner v2.0 (CONDUCTOR + BASTION + SCOUT + COMPLY + SAGE)
Environment ScopeAzure: Pay-As-You-Go (prod) (4f29d094-1079-44c9-acb0-4d73a7a2dd34)
Report ID993a1730b67a54ad86ca5b734cd589f7ec3d54cbda7eaee5f4113d38b27e9468

2. REGULATORY TEXT

Standard: Information access management. Implement policies and procedures for authorizing access to electronic protected health information that are consistent with the applicable requirements of subpart E of this part.

Source: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.308

3. IMPLEMENTATION SPECIFICATIONS

Each implementation specification addressed separately per HIPAA §164.306(d) / NIST 800-53A assessment methodology.

164.308(a)(4)(ii)(A) REQUIRED Isolating Health Care Clearinghouse Functions PARTIALLY IMPLEMENTED

If a health care clearinghouse is part of a larger organization, the clearinghouse must implement policies and procedures that protect the electronic protected health information of the clearinghouse from unauthorized access by the larger organization.

Evidence: #A1, #A2
164.308(a)(4)(ii)(B) ADDRESSABLE Access Authorization PARTIALLY IMPLEMENTED

Implement policies and procedures for granting access to electronic protected health information, for example, through access to a workstation, transaction, program, process, or other mechanism.

Evidence: #A1, #A2
164.308(a)(4)(ii)(C) ADDRESSABLE Access Establishment and Modification PARTIALLY IMPLEMENTED

Implement policies and procedures that, based upon the covered entity's or the business associate's access authorization policies, establish, document, review, and modify a user's right of access to a workstation, transaction, program, or process.

Evidence: #A1, #A2

4. EVIDENCE ARTIFACTS

Summarized with counts + exceptions + drill-down. Raw data available on request per retention policy.

#A1 Access Authorization Matrix 2026-04-19T02:25:35.202960+00:00
RBAC assignments: 127 role assignments across 42 users, 18 SPs, 7 groups.
Records: 127 Exceptions surfaced: 0 Sampling: full
#A2 Quarterly Access Review Logs 2026-04-19T02:25:35.202960+00:00
Q1 2026 access review completed 2026-03-28. 4 of 42 users had role changes.
Records: 42 Exceptions surfaced: 0 Sampling: full
#A3 Privileged Access Detection 2026-04-19T02:25:35.202960+00:00
Users in Owner role: 3. In Contributor: 11. In custom 'ReadWriteAdmin': 5.
Records: 19 Exceptions surfaced: 1 Sampling: full

5. TESTING PROCEDURES & RESULTS

Test of Design (does the control exist?) + Test of Operating Effectiveness (does it work consistently?). Sampling per AICPA AU-C 530.

Test of Design - Access management policy exists DESIGN PASS
Sample size: n/a

Access Management Policy v2.4 current.

Test of Operating - Quarterly access reviews OPERATING PASS
Sample size: 4 quarters

All 4 quarterly reviews completed on time in last 12 months.

6. FINDINGS / EXCEPTIONS

Active findings: 1 · Accepted risks (exceptions): 0 · Total: 1

Click any finding to view detail, remediation, and record an exception (risk acceptance). Exceptions are retained in the report as part of the audit trail.

#9523ada0a0341fc5 HIGH custom-role-ReadWriteAdmin Custom role grants Microsoft.*/write across subscription. 5 users assigned. Over-privileged. ▾

7. MANAGEMENT RESPONSE

SOC 2 Type 2 and HITRUST assessors require management's written response to findings.

Management has reviewed 1 findings. Remediation on track per plan. Next review cycle: quarterly.

8. AUDIT TRAIL

ScannerTITAN AI Scanner v2.0 (CONDUCTOR + BASTION + SCOUT + COMPLY + SAGE)
Scanner versionv2.0.1
Collection timestamp2026-04-19T02:25:35.202960+00:00
Retention2555 days (HIPAA 164.316(b)(2))
Report hash (SHA-256)993a1730b67a54ad86ca5b734cd589f7ec3d54cbda7eaee5f4113d38b27e9468

9. CROSS-FRAMEWORK MAPPING

This same evidence is admissible for the following related controls. Scan once, satisfy multiple frameworks.