Review of User Access Rights

The HITRUST “Review of User Access Rights” requirement means you must run a formal, recurring access review and also trigger reviews after role changes (promotion, demotion) and employment termination, then remove excess privileges. Operationalize it by defining review frequency and scope, generating authoritative access lists, obtaining documented manager/system-owner attestations, tracking remediation, and retaining evidence. ¹

Key takeaways:

• Run access reviews on a defined cadence, and also event-driven after HR changes. ¹
• Use a formal process: defined scope, clear reviewers, documented decisions, and tracked removals. ¹
• Evidence matters: exportable access listings, review sign-offs, remediation tickets, and proof of privilege removal. ¹

“Review of user access rights” is a simple control that fails in complex environments: identity lives in an IdP, privileges live in apps, groups, databases, and cloud consoles, and ownership is spread across IT, security, and business teams. HITRUST CSF v11 01.e focuses on two things: (1) periodic reviews using a formal process, and (2) reviews after changes like promotion, demotion, or termination, followed by removal of excess privileges. ¹

For a CCO, GRC lead, or compliance officer, the operational goal is straightforward: prove that access is appropriate for each user’s current job duties, and prove you correct exceptions promptly. Auditors typically do not accept “we have SSO” or “managers approve access when requested” as a substitute for an actual review with records. You need a repeatable workflow that produces the same types of artifacts every cycle, across your in-scope systems, with clear accountability for remediation.

This page gives requirement-level implementation guidance you can execute quickly, without guesswork.

Regulatory text

HITRUST CSF v11 01.e (excerpt): “Management shall review users' access rights at regular intervals using a formal process. User access rights shall be reviewed after any changes, such as promotion, demotion, or termination of employment, and excess privileges shall be removed.” ¹

What the operator must do: establish (a) a recurring access review cadence and (b) event-driven reviews tied to HR/role changes and terminations, then document decisions and remove access that is no longer justified. The control is not satisfied by having a policy alone; you need execution records that show the review happened and that excess privileges were removed. ¹

Plain-English interpretation

You must periodically confirm that each person’s access still matches their current responsibilities, and you must re-check access whenever someone’s role or employment status changes. If they have access they no longer need, you remove it and keep proof you did so. ¹

Who it applies to (entity and operational context)

Entity types: all organizations seeking to align with HITRUST CSF requirements. ¹

Operationally, this applies wherever:

• Users (employees, contractors, interns) access systems that store or process sensitive data.
• Privileges are granted through roles/groups, direct entitlements, shared admin consoles, database permissions, or application-level permissions.
• Third parties have access (support vendors, billing providers, consultants). HITRUST’s “users” concept includes any identity that can log in and perform actions; treat third-party identities the same way you treat internal ones for review and removal.

Systems typically in scope:

• Identity providers (SSO/IdP), directory services, privileged access management where used
• Key business apps (EHR/EMR, billing, HRIS, CRM, ticketing, file sharing)
• Cloud control planes and infrastructure platforms
• Databases and analytics platforms if access is not fully governed by the IdP

What you actually need to do (step-by-step)

Step 1: Define “regular intervals” and “formal process” for your environment

HITRUST does not specify a frequency in the excerpt, so you must set one and document it as part of the formal process. ¹

Minimum process decisions to document:

• Review cadence (what “regular intervals” means for your organization)
• In-scope systems (systems and permission types covered)
• Reviewer roles (e.g., people managers for workforce users, system owners for privileged roles)
• Approval criteria (what makes access “appropriate,” e.g., job role mapping, least privilege)
• Remediation SLA target (a target you set for how quickly exceptions must be removed)
• Exception handling (how you record and approve temporary access or justified over-privilege)

Output artifact: Access Review Procedure (1–3 pages) referenced by your access control policy.

Step 2: Build authoritative user and access inventories

Access reviews fail when the input list is incomplete or inaccurate.

Create two inventories:

1. User population list: source from HRIS + contractor roster + third-party access register (if you have one).
2. Entitlements list per system: for each in-scope system, generate an export of users and their effective privileges (roles, groups, admin flags, database roles).

Practical approach:

• Prefer system-generated exports (CSV, screenshots with timestamps, admin reports) over manually curated spreadsheets.
• For SSO-connected apps, confirm whether authorization is controlled by IdP groups or inside the application. If inside the application, your review must include the app’s internal roles, not just SSO assignment.

Output artifacts:

• Export files (dated), query screenshots, admin reports
• A reconciled “review package” that ties user identity to entitlement(s)

Step 3: Execute the periodic review (attestation + validation)

A formal access review should include both:

• Attestation: the reviewer confirms the access is still required.
• Validation: spot checks for risk signals (privileged roles, dormant accounts, shared accounts, access outside job family).

Recommended reviewer model:

• Line manager attests to workforce users’ access to business applications.
• System owner/admin attests to privileged roles and technical entitlements.
• Security/GRC monitors completion, exceptions, and remediation closure.

Practical checklist for reviewers (put this in the review form):

• Is the user still active and assigned to the correct team?
• Does their access align to a defined role/group, or is it direct assignment that should be removed?
• Do they have privileged/admin access? If yes, is there documented justification?
• Is the access still needed for current duties after any org changes since the last review?

Output artifacts:

• Completed attestation records (ticket, GRC workflow, signed spreadsheet, or e-sign tool export)
• Evidence of reviewer identity and date/time of completion

Step 4: Run event-driven reviews for changes (promotion, demotion, termination)

HITRUST explicitly requires access review after changes and removal of excess privileges. ¹

Operationalize with triggers:

• HRIS change feed (role/department changes) generates a task to re-check access for that user.
• Termination event triggers immediate deprovisioning and a follow-up review to confirm removal across systems that do not automatically deprovision.

Common gap: teams only disable the IdP account. You still need to confirm downstream access is removed where local accounts or API keys exist.

Output artifacts:

• HR change report (or ticket evidence) tying the event to the access review
• Deprovisioning logs from IdP/apps
• Tickets showing privilege removals completed

Step 5: Remediate excess privileges and close the loop

A review without cleanup does not meet “excess privileges shall be removed.” ¹

Remediation workflow:

• Log exceptions in a ticketing system with clear action owners.
• Remove or downgrade access (group removal, role change, permission revocation).
• Capture proof: before/after exports, screenshots, or system logs.
• Track completion and retain closure evidence with the review package.

Step 6: Retain evidence in an audit-ready format

Keep each review cycle in a single folder/package:

• Scope statement
• Source exports
• Completed attestations
• Exception list + remediation tickets
• Proof of removal
• Management reporting (completion status, overdue items)

If you use Daydream to run control operations, store review workflows, reviewer assignments, and remediation evidence in one place so you can produce a consistent audit packet per system and per cycle without rebuilding spreadsheets.

Required evidence and artifacts to retain

Retain artifacts that prove who reviewed what, when, what they decided, and what changed:

• Access review procedure (defines “regular intervals” and “formal process”) ¹
• In-scope system list and access models (roles/groups/privileges)
• System-generated user/entitlement exports (dated)
• Attestation results (approvals/denials) with reviewer identity
• Exception register (what was “excess,” rationale, owner, due date)
• Remediation tickets and completion proof (before/after access state)
• HR event evidence for promotions/demotions/terminations mapped to review and removal steps ¹

Common exam/audit questions and hangups

Expect these to drive evidence requests:

• “Define ‘regular intervals.’ Where is that documented?” ¹
• “Show me the last completed access review for System X and the remediation.” ¹
• “How do you know the population is complete (employees + contractors + third parties)?”
• “How do you handle role changes? Show examples tied to HR events.” ¹
• “How do you ensure excess privileges were removed, not just identified?” ¹
• “Who reviews privileged access, and how do you prevent self-approval?”

Hangups that slow audits:

• Access listings pulled manually with no reproducible method.
• Reviews performed but no remediation evidence.
• “Manager approved access” records at request time, but no periodic review records.

Frequent implementation mistakes and how to avoid them

Mistake	Why it fails	Avoid it by doing this
Reviewing only the IdP app assignment	Authorization often lives inside the app or in cloud/IAM roles	Include effective permissions per system (app roles, cloud roles, DB roles)
Treating termination as “disable SSO”	Local accounts, tokens, service access can remain	Confirm removal across apps; verify no active local accounts
Allowing self-review for admins	Auditors flag weak segregation of duties	Require system-owner or security review for privileged roles
No documented cadence	“Regular intervals” becomes subjective	Define and publish a cadence; track completion against it 1
Tracking exceptions in email	No audit trail or closure proof	Use tickets or a GRC workflow with timestamps and owners
Ignoring third-party users	Third parties can have powerful access	Include third-party identities in the user population and event-driven reviews

Risk implications (why this control matters operationally)

If access rights are not reviewed and corrected, you accumulate “permission debt”: users retain rights after transfers, contractors keep accounts after projects end, and privileged access spreads quietly. That increases the likelihood that an internal account misuse or compromised credential leads to broader exposure than necessary. From a compliance standpoint, weak evidence on access reviews is a recurring audit finding because it is easy for assessors to sample and validate.

Practical 30/60/90-day execution plan

First 30 days (stand up the process)

• Define review cadence and event-driven triggers in a written procedure. ¹
• Pick initial in-scope systems based on where sensitive data and privileged access exist.
• Identify reviewers (managers, system owners) and set a review calendar.
• Build export methods for each system and test that you can produce entitlement lists on demand.

Next 60 days (run the first real cycle)

• Execute the first periodic review for the highest-risk systems.
• Track exceptions in tickets; remove excess access and capture proof. ¹
• Pilot HR change-driven reviews: select several recent role changes/terminations and prove the full workflow (trigger → review → removal → evidence). ¹

Next 90 days (scale and harden)

• Expand to remaining in-scope systems and standardize the review package format.
• Add quality checks: completeness of user population, privileged access separate review, and remediation closure reporting.
• Move from spreadsheets to a system of record (GRC workflow or Daydream) so assignments, sign-offs, and evidence collection are consistent across cycles.

Frequently Asked Questions

What counts as “regular intervals” for access reviews under HITRUST?

The requirement mandates regular intervals but does not prescribe a specific frequency in the provided excerpt. Set a cadence based on risk and document it in your formal process, then prove you meet it with completed review records. ¹

Do we need to review access after every promotion or transfer?

Yes, the excerpt explicitly calls out review after changes such as promotion or demotion. Implement an HR-triggered workflow so role changes reliably create an access re-evaluation task and excess privileges get removed. ¹

Is disabling SSO enough for terminations?

Often no. You still need to confirm access removal in systems with local accounts, API tokens, or separate admin consoles, and keep evidence showing excess access was removed after termination. ¹

Who should perform the access review: IT, security, or managers?

Assign reviews to the people who can attest to business need (managers) and the people who understand technical privileges (system owners/admins). GRC should oversee completion and evidence quality, not approve their own access.

What evidence do auditors usually ask for?

They ask for the access listing used for review, proof of reviewer sign-off, and proof that exceptions were remediated (tickets and before/after access state). They also commonly test role-change and termination samples against your event-driven review requirement. ¹

How do we handle third-party access in user access reviews?

Treat third-party identities as “users” for purposes of the review. Include them in the population, ensure a business sponsor attests to continued need, and tie offboarding to contract end or access expiration dates.

Footnotes

1. HITRUST CSF v11 Control Reference