Separation of Primary and Alternate Providers
High Risk
Moderate
Medium Cost
CP-8(3) (Separation of Primary and Alternate Providers) enhances base CP-8 within the NIST Contingency Planning family. Base CP-8 sets the foundational expectation; this enhancement adds specificity: Obtain alternate telecommunications services from providers that are separated from primary service providers to reduce susceptibility to the same threats. Threats that affect telecommunications services are defined in organizational assessments of risk and include natural disast. Covered entities and business associates apply it to downtime procedures, backup/restore, and alternate processing that keep clinical operations and ePHI available.
Control Objective
Implement Separation of Primary and Alternate Providers so organization-defined contingency planning safeguards operate consistently on systems and networks that handle ePHI, with measurable evidence for HIPAA and NIST assessments.
Implementation Guidance
- Map CP-8(3) to systems in scope (EHR, imaging, lab, pharmacy, billing, identity, backups, and BA connections).\n2. Translate “Separation of Primary and Alternate Providers” into technical settings, procedures, or architecture patterns owned by named roles.\n3. Prefer enforceable controls (config, automation, mediation) over awareness-only measures where feasible.\n4. Integrate with change, incident, and downtime processes so clinical operations are not surprised.\n5. Log and retain evidence of operation (tickets, configs, test results) aligned to audit needs.\n6. Include vendors/BAs in contracts and connection standards when they touch the control surface.\n7. Test after major EHR, network, or cloud changes — upgrades often reset protections.\n8. Review exceptions at least quarterly; expire “temporary” holes that expose ePHI paths.
Real-World Use Cases
How this control shows up in healthcare and HIPAA-covered environments.
Best Practices
- Name an owner for CP-8(3) in the SSP control matrix.\n- Favor system enforcement on ePHI paths over informal email approval.\n- Measure coverage: percent of in-scope clinical systems where the enhancement operates.\n- Review exceptions quarterly with security and clinical informatics.\n- Feed relevant events to SIEM with a named use case.\n- Keep a one-page evidence pack (config + sample log + last test) ready for assessors.
Common Gaps & Violations
- Policy cites CP-8(3) but production EHR/network paths show no enforcement of separation of primary and alternate providers.\n- Permanent exceptions with no expiry for vendors or “special” clinics.\n- Control implemented only on corporate IT — clinical devices and interfaces omitted.\n- No logs or test records; reliance on tribal knowledge.\n- Major upgrade silently disabled the enhancement.
Required Documentation
- Procedure/standard for Separation of Primary and Alternate Providers (CP-8(3))\n- Architecture or configuration baselines showing enforcement points\n- Exception register with owners and expiry\n- Sample logs, alerts, or test results\n- Training or runbook references for clinical/IT operators
How to Test & Validate
- Attempt a prohibited or out-of-policy action related to separation of primary and alternate providers; confirm block, alert, or required workflow.\n2. Complete an authorized clinical/IT path; confirm success and logging.\n3. Sample open exceptions for approval and expiry.\n4. Verify at least one EHR-adjacent and one BA/vendor path are in scope.\n5. Confirm evidence retained for the last 90 days (or per policy).
Audit Considerations
Assessors look for operating evidence of Separation of Primary and Alternate Providers on systems touching ePHI — configs, logs, restore/DR artifacts, or failed-test results — not only a policy paragraph referencing CP-8(3).
HIPAA Mapping
How this NIST control supports HIPAA Security Rule expectations.
- 164.308(a)(7) Contingency Plan — data backup, disaster recovery, and emergency-mode operations for ePHI.\n- 164.308(a)(7)(ii)(A) Data Backup Plan — retrievable exact copies of ePHI.\n- 164.308(a)(7)(ii)(B) Disaster Recovery Plan — restore lost data after disruption.\n- 164.312(a)(2)(ii) Emergency Access Procedure — continue critical access during contingency.
Compliance Tips
- List CP-8(3) explicitly in the system security plan with system inventory references.\n- Prioritize emergency department, inpatient EHR, and remote access paths first.\n- Bundle evidence with related HIPAA contingency or transmission-security narratives where they overlap.
References & Resources
- NIST SP 800-53 Rev. 5 — CP-8(3)\n- Related controls: CP-8
Related Guidelines
Related controls that commonly accompany CP-8(3).
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