This bill mandates that health insurers must provide a detailed explanation for any denial of coverage related to private duty nursing services, particularly when such services have been deemed medically necessary by the patient's physician. If a payer denies a prior authorization request, they are required to fully describe the reason for the denial. In cases where the denial is based on the assertion that the services are not medically necessary, the insurer must also explain why the physician's determination is considered invalid. Furthermore, the bill stipulates that insurers must outline the criteria used to evaluate prior authorization requests and provide examples of situations in which such requests are approved, along with the necessary documentation for those approvals.

The bill aims to enhance transparency in the decision-making process of health insurers regarding private duty nursing services, ensuring that patients and their healthcare providers understand the rationale behind coverage denials. This legislation is set to take effect 90 days after its enactment.