Free Practice Questions for HITRUST CCSFP Exam

HITRUST does not determine scope in disputes between clients and assessors.

The organization (subscriber) ultimately owns responsibility for defining and attesting to the assessment scope.

The External Assessor is responsible for verifying that the defined scope is reasonable, complete, and appropriate.

HITRUST only reviews submitted assessments for quality assurance but does not directly arbitrate scope disagreements.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Guidance [0027]):

Subscribers determine scope; External Assessors validate scope appropriateness. HITRUST does not dictate or resolve scope disputes.

Scoping an assessment involves identifying regulatory factors that apply to an organization’s operations. In this case, the entity is a pharmacy that accepts Medicare/Medicaid and processes credit cards. Medicare/Medicaid participation introduces obligations under CMS Minimum Security Requirements (High), which adds federal requirements specific to healthcare entities working with Centers for Medicare and Medicaid Services. Credit card acceptance triggers applicability of the Payment Card Industry Data Security Standard (PCI-DSS), a widely recognized standard for protecting cardholder data. Additionally, pharmacies often fall under the FTC Red Flags Rule, which applies to organizations that maintain consumer accounts and must protect against identity theft. By contrast, FISMA applies to federal agencies or contractors, not pharmacies, and FedRAMP applies only to cloud service providers working with the federal government. Therefore, the correct set of regulatory factors is FTC Red Flags Rule, PCI-DSS, and CMS Minimum Security Requirements (High).

HITRUST certifications apply to implemented systems and environments, not products, individuals, or facilities. For example, a healthcare provider may certify its electronic health record (EHR) platform, data center, and IT operations supporting PHI. HITRUST does not certify products like software applications sold to customers; instead, it certifies how organizations implement and operate them securely. Similarly, while HITRUST offers professional credentials like CCSFP or CHQP for people, these are certifications of knowledge, not organizational assurance. Facilities are included in assessments as scoping components but are not independently certified. The certification is always tied to an organization’s operational environment as validated through a CSF assessment.

For r2 Validated Assessments, certification requires meeting HITRUST’s minimum scoring thresholds across all applicable areas (commonly ≥62.5%). If any domain (or required control reference/requirement) falls below the threshold (e.g., <61 or <62.5 as applicable), the assessment cannot be certified and will be issued as a Validated Report without Certification.

“If any required scoring area is below the minimum threshold, the outcome is a Validated Report without Certification until deficiencies are remediated.” [HITRUST CSF Assurance Program – Certification Criteria, 0142]

The Readiness Assessment is designed to give organizations flexibility when evaluating their security and compliance posture. Unlike validated assessments, which are bound by specific methodologies, thresholds, and QA requirements, the readiness format allows entities to scope assessments more freely. This includes the ability to select any HITRUST authoritative source, such as HIPAA, PCI-DSS, NIST, ISO, or GDPR, for self-assessment purposes. The readiness option is often used for gap analysis, remediation planning, and preparing for a future validated assessment. Since the results are not submitted to HITRUST QA, organizations can tailor the assessment to their needs without external restrictions. Neither e1, i1, nor r2 assessments provide this level of flexibility, as those validated assessments are standardized and tightly controlled.

HITRUST issues certifications only for the HITRUST CSF (e.g., e1, i1, r2 certifications and designated privacy/AI certifications as defined by the program). While the CSF maps to and harmonizes with other frameworks and regulations (e.g., NIST SP 800-53, ISO/IEC 27001/27002, PCI-DSS), HITRUST does not issue certifications for those external standards.

“HITRUST provides certification against the HITRUST CSF. External standards and regulations are integrated as authoritative sources and mappings but are not certified by HITRUST.” [CCSFP Program Overview – Certifications & Mappings, 0017]

HITRUST does not permit marking a requirement statement “Not Applicable” simply because most of the evaluative elements don’t apply. Requirement statements are mandatory unless a legitimate scoping or regulatory justification supports exclusion. For example, a control related to cardholder data could be marked N/A only if the organization does not process credit cards. However, if even one evaluative element applies, the requirement must be scored, and the non-applicable elements may be documented as part of evidence. HITRUST QA reviews all N/A designations, requiring organizations to justify exclusions in the Subscriber Comments field. Improperly marking requirements as N/A may result in assessment rejection or mandatory CAPs.

The NIST Cybersecurity Framework (CSF) Report in HITRUST is a derivative output that is automatically generated within the MyCSF platform. When an entity completes a HITRUST assessment (e1, i1, or r2), MyCSF uses the mapping of HITRUST control requirements to the NIST CSF categories and subcategories to produce the report. Because these mappings are embedded into the framework, assessors do not need to perform additional testing, create mappings manually, or provide separate evidence. The effort invested in validating HITRUST requirement statements is sufficient, and MyCSF generates the NIST CSF alignment report as an output. This provides organizations with the ability to demonstrate NIST CSF alignment to stakeholders without duplicating work. Therefore, additional work is not required from assessors—making the correct answer No.

The HITRUST CSF scoring rubric evaluates maturity across five levels: Policy, Procedure, Implemented, Measured, and Managed. To achieve certification in an r2 assessment, each domain must meet a minimum aggregate threshold of 71. Full compliance in Policy, Procedure, and Implementation (100% each) results in high scores that exceed the certification threshold. The Measured and Managed levels, while valuable for demonstrating monitoring and governance, are not required to be scored above zero to achieve certification. In this scenario, the organization demonstrates complete documentation and implementation of controls, which satisfies HITRUST’s certification criteria. Therefore, even with Measured and Managed at zero, the assessment can achieve certification because the foundational maturity levels provide sufficient assurance.

HITRUST does not issue certifications limited solely to privacy-related requirements. While privacy is a critical part of the CSF—reflected in domains such as Data Protection & Privacy—HITRUST certifications require coverage of all 19 domains. This is because security and privacy are interdependent: without robust security, privacy cannot be protected. An entity may emphasize privacy controls during scoping and reporting, but certification itself is always tied to a full CSF assessment. Privacy-related frameworks, such as GDPR or HIPAA Privacy Rule, can be added as regulatory factors, which introduce additional privacy-focused requirements. However, the output will still be a standard HITRUST validated report or certification covering the entire environment, not a “privacy-only certification.”