The Role of Utilization Review Nurses in Promoting Appropriate Use of Health Services within Thailand’s Public Health Insurance Schemes: A Narrative Literature Review and Evidence Gaps
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Abstract
Thailand's public health insurance schemes face pressure to use resources efficiently. Utilization Review (UR) nurses have been proposed as one mechanism to promote appropriate service use, but evidence on this role in the Thai context has not been synthesised.
The objectives to (1) synthesise the roles and processes of UR nurses, (2) identify factors related to the effectiveness of UR, and (3) appraise the evidence on UR/pre-claim review in Thailand's public health insurance schemes.
This narrative review, reported according to SANRA, searched PubMed, Scopus, Google Scholar, ScienceDirect, ThaiJO, and the websites of the National Health Security Office and the ABIM Foundation (June 2025–June 2026). Ten core documents were synthesised by content analysis using a five-domain coding framework; 46 supporting documents informed concepts and context.
Four themes emerged: (1) inappropriate and low-value care has multilevel drivers; (2) appropriateness assessment relies on clinical criteria and tools that need contextual adaptation; (3) documents describing the UR nurse role are largely descriptive, covering screening, record review, appropriateness assessment, multidisciplinary coordination and decision support; and (4) information technology and artificial intelligence are beginning to support UR in Thailand. No study evaluated the effect of UR nurses on low-value care or patient outcomes in Thailand, and no empirical evidence on pre-claim review was found among the selected documents.
The literature suggests that UR nurses' roles may extend from benefit and documentation checks to data-informed quality improvement, but this rests mainly on descriptive and conceptual sources. Evidence that UR nurses reduce low-value care or improve care value is lacking. Outcome evaluation, competency frameworks and safeguards against conflicts of interest are needed.
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This article is published under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0), which allows others to share the article with proper attribution to the authors and prohibits commercial use or modification. For any other reuse or republication, permission from the journal and the authors is required.References
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