By Elizabeth McElhiney, MHA, CHPS, CPHIMS, CRIS
Director of Compliance and Government Affairs
Verisma
September 30, 2024
Annoyed and confrontational requestors may challenge the content provided in response to a request for medical records because they don’t think they received the precise information requested. These complaints can happen when requestors are unfamiliar with the minimum necessary standard.
If your organization adheres to its policies, it’s likely you’re compliant with HIPAA provisions despite pushback from requestors. Your organization isn’t required to spend hours sifting through the medical records and parsing out information to spare a requestor spending time to locate the information they deem relevant.
What’s HIPAA minimum necessary standard?
Covered entities and business associates are required by the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule)[1] to take reasonable efforts to limit the release of protected health information (PHI) to the minimum necessary to accomplish the intended purpose of the request,[2] often referred to as the minimum necessary standard. It’s designed to be flexible and places the authority with the covered entity to determine implementation.[3]
How does the minimum necessary requirement rule work?
A healthcare organization must develop and implement policies and procedures appropriate for its organization and reflect the business practices and workforce. The organization’s policies and procedures must identify who needs access to PHI to fulfill job responsibilities, categories of PHI needed, and conditions where access is appropriate. For instance, a hospital can permit doctors, nurses or others involved in treatment to have access to the full medical record. When the entire medical record is necessary, the organization’s policies and procedures must state so and include a justification.
When does the minimum necessary standard not apply?
- Healthcare providers making a request for treatment purposes
- Patients when they request for their records
- Requests with valid authorization
- Requests required for compliance with HIPAA Administrative Simplifications Rules
- U.S. Department of Health and Human Services (HHS) requests for disclosure of information required under the Privacy Rule for enforcement purposes
- When the request is required by law
Who decides what’s minimum necessary?
A covered entity may rely on its business associate re: the minimum amount of information needed for a reasonable request to disclose PHI. Covered entities can defer to Verisma and let us handle the burden. As a trusted business associate, we provide requestors with the right information. Covered entities entrust us with PHI, and we have an obligation to disclose information correctly. We’ve developed policies and procedures for implementing the minimum necessary standard so our fulfillment of applicable requests is compliant with the Privacy Rule.
Verisma and your minimum necessary policy
We do what’s in the best interest of our clients. During the implementation process, we’ll work together to make sure we have a clear understanding of what minimum necessary means for your organization.
Learn more by contacting our team of healthcare data experts.
[1] 45 CFR Part 160 and Part 164, Subparts A and E
[2] 45 CFR 164.502(b)
[3] https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/minimum-necessary-requirement/index.html